Abdominal Wall Hernias Classification, Diagnosis and Complications Notes

Hernia Introduction

• Hernia is not a disease but a manifestation of a disease. Several factors may contribute to the development of a hernia (They have been discussed later.)
• Hernia is a common condition affecting patients, especially inguinal hernia in males and incisional hernia in females.

Read And Learn More: Gastrointestinal Surgery Notes

• Even though several types of surgery have been described for hernias, mesh hernioplasty remains the gold standard treatment.
  • The majority of the hernias require surgical treatment leaving apart small asymptomatic direct hernias in the elderly.
  • Today, laparoscopic hernia is becoming a gold standarObstructed hernia is an emergency and late cases carry significant mortality.
  • As far as students are concerned, hernia is the most common case in the examination. Hence, a detailed clinical examination of hernia, complications, various types of hernias, and their treatment.
• Hernia means to bud, protrude, or rupture (Latin).

Hernia Definition

Abnormal protrusion of a viscus or a part of it through a weak point in the body (opening) is known as a herniInguinal hernia occurs either through the deep inguinal
ring (indirect hernia) or through the posterior wall of the inguinal canal (direct hernia).

Anatomy Of The Inguinal Region

Inguinal Ligament (Poupart’s Ligament) 

• It is the ligamentous portion of the external oblique aponeurosis which folds inwards and extends from the anterior superior iliac spine to the pubic tubercle.
• The midpoint between these two structures is called the midpoint of the inguinal ligament.

Inguinal Hernia Anatomy

Lacunar Ligament (Gimbernat’s Ligament)

• Some fibers of the inguinal ligament pass posteriorly to attach to the superior pubic ramus lateral to the tubercle and form the lacunar ligament.
• The midpoint between the anterior superior iliac spine and pubic symphysis is called mid inguinal point.

Inguinal Canal 

It is 4 cm in length extending from the deep inguinal ring to the superficial inguinal ring.

Inguinal Hernia Anatomy

Deep Ring (Internal Ring) 

It is a U-shaped defect in the fascia transversalis which forms the posterior wall of the inguinal canal. It lies 1.25 cm above the midpoint of the inguinal ligament.

External Ring (Superficial Ring)

The superficial ring is a triangular defect in external oblique aponeurosis. It is bounded by the lateral and medial crura formed by the external oblique aponeurosis and the base of the triangle is formed by the pubic crest.

Boundaries of Inguinal Canal

• Anterior: External oblique aponeurosis and a few fibers of the conjoined muscle (especially of internal oblique) laterally.
• Superior: Arched fibers of the conjoined muscle.
• Inferior: Inguinal ligament and the lacunar ligament on the medial side (Gimbernat’s ligament).
• Posterior: Fascia transversalis and the conjoined tendon medially. Thus, the inguinal canal is strong in the lateral part anteriorly and the medial part posteriorly.

Inguinal Hernia Anatomy

Contents of Inguinal Canal

• Spermatic cord
• Ilioinguinal nerve
• Genital branch of genitofemoral nerve
• Round ligament in females
• Vestigial remnant of processus vaginalis sac

Myopectineal Orifice of Fruchaud

Hernia Symptoms

• This weak area is the site of all groin hernias according to Fruchaud.

Contents of the Spermatic Cord

• Vas deferens
• Testicular artery
• Artery to the vas
• Cremasteric artery
• Pampiniform plexus of veins
• Lymphatics
• Sympathetic nerves
• Genital branch of genitofemoral nerve
• Processus vaginalis.

Inguinal Hernia Anatomy

Ilioinguinal Nerve

• The ilioinguinal nerve is a branch of the first lumbar nerve (L1). It separates from the first lumbar nerve along with the larger iliohypogastric nerve. It pierces the transversus abdominis and internal oblique muscles to enter the inguinal canal from the side
• The ilioinguinal nerve does not pass through the deep inguinal ring. It only travels through part of the inguinal canal.
• After going through the inguinal canal, it pierces the internal oblique muscle, distributes nerve fibers to it, and then accompanies the spermatic cord through the superficial inguinal ring.
• Divides into anterior scrotal nerve/anterior labial nerve.
• Supplies the skin of the upper and medial part of the thigh, scrotum/vulva.
• Entrapment or injury to the ilioinguinal nerve is one of the causes of post-herniorrhaphy pain.
• Hence, a few recommend division of the ilioinguinal nerve during hernia surgery.

• It is the area between the inguinal ligament anteriorly and iliopubic tract posteriorly.
• Iliopubic tract: It is the thickened inferior margin of the transversal fascia which appears as a fibrous band running parallel and posterior (deep) to the inguinal ligament. It inserts into the superior pubic ramus to form a lacunar ligament.
• Boundaries of myopectineal orifice of Fruchaud:
• Superiorly: Arched fibers of the internal oblique
• Laterally: Iliopsoas muscle
• Medially: Lateral border of rectus abdominis muscle
• Inferiorly: Pubic pecten—Cooper’s ligament—bony margin of the pelvis.

Inguinal Hernia Anatomy

• Surgical importance of iliopubic tract: Recognition of this is a part of laparoscopic repair (initial step)— visualizing from within.
• This structure reinforces the posterior wall and floor of the inguinal canal as it bridges structures traversing subinguinal space. Hesselbach’s triangle.
• It is bounded medially by the lateral border of the rectus abdominis muscle, laterally by the inferior epigastric artery, and inferiorly by the inguinal ligament.
• Direct hernias occur commonly through Hesselbach’s triangle (medial), and indirect hernia lateral to inferior epigastric artery.

Aetiology Of Hernia – What Causes Hernia?

• An indirect hernia occurs largely due to persistent processus vaginalis manifestations of this can be seen in elderly patients in whom an indirect hernia can be triggered by some factors which increase intraabdominal pressure.
• A direct hernia occurs mainly due to weakness of transversalis fascia in Hesselbach’s however, an increase in abdominal pressure due to chronic cough, constipation or difficulty in passing urine, development of ascites (portal hypertension, nephrotic syndrome), can precipitate the development of a hernia.
• Collagen and hernia: Few studies involving studying fibers of transversalis fascia have proved that few cases of primary inguinal hernias and recurrent hernias occur due to intrinsic and inherent weakness in the tissue.
  • Type 1 Collagen: It is characteristic of mature scars or fascial tissues.
  • Type 3 Collagen: It is mechanically unstable, less cross-linked collagen synthesized during the early days of wound healing.
  • For adequate strength and function of transversalis fascia, the presence of collagen in adequate amounts is important. The decreased tensile strength of collagen type 3 plays a key role in the development of incisional hernias.
  • Collagen disorder: In prune-belly syndrome, collagen fiber disorder causes the development of not only hernias but also interstitial hernias, bilateral hernias, and hernias due to inherited imbalance in the types of collagens.

Hernia Symptoms

Abdominal Hernais Risk Factors

It can be classified as patient-related and external factors.

1. Abdominal Hernais Risk Factors Patient-related:
   • A patent processus vaganalis chance of developing a hernia in males is about 20–25%.
   • Some other factors responsible are failed obliteration of the processus vaginalis (PV) sac, persistent smooth cells, and insufficient calcitonin gene-related peptide from the spinal nucleus of the genitofemoral nerve. Smooth cells help in propelling the testis into the scrotum.
   • Hernias are more common on the right side in children because the right PV sac is obliterated later than the left PV sac.
2. Abdominal Hernais Risk Factors External factors:
   • Smoking causes increased collagen degradation and decreased synthesis. This is due to the effect of nicotine, which weakens the abdominal wall.
   • Increased abdominal pressure caused by coughing, jumping, and lifting of the load has been mentioned.
   • Constipation has a doubtful relationship.

• Summary of various factors for the development of hernias have been summarized.

Hernia Surgery

Abdominal Hernais Risk Factors – Aetiology/Causes of Hernia

1. Congenital:
   • Persistent processus vaginalis sac: Chief cause of indirect hernia.
2. Collagen fiber disorder
   • Prune-belly disorder—congenital
   • Smoking: Acquired collagen deficiency
3. Corpulence obesity
4. Chronic causes of increased intra-abdominal pressure
   • Chronic cough, chronic constipation, straining at micturition, ascites
5. Conjoined tendon weakness/rupture of a few fibers following:
   • Lifting heavy weight
   • Postappendicectomy—injury to the ilioinguinal nerve.
   • Chronic illness/debilitating disease causing weakness of transversalis fascia in the Hesselbach’s area

Inguinal Defence Mechanisms

1. Obliquity of the inguinal canal (in children, it is straight).
2. During straining or coughing, the conjoined tendon contracts, and since it forms the anterior, superior, and posterior boundaries, it closes the inguinal canal—shutter or sphincter-like effect.
3. Increased intra-abdominal pressure produces a plugging effect at the external ring. The deep ring is pulled upwards and laterally because it is adherent to the posterior surface of the transversalis muscle. This occludes the ring and prevents the herniation—ball valve effect.

Hernia Surgery

Classification Of Hernia

1. Anatomical classification:
   1. Indirect hernia,
   2. direct hernia.
2. Nyhus classification: This classification is based primarily on the defect, which helps in planning an appropriate repair.

• Type 1: Indirect hernia with normal deep ring— normal posterior wall
• Type 2: Indirect hernia with dilated deep ring— normal posterior wall
• Type 3: Based on posterior wall defect:
  1. Direct Hernia,
  2. Pantaloon, Sliding—Enlarged Deep Ring,
  3. Femoral
• Type 4: Recurrent Hernia—Direct, Indirect Femoral, Combined.

Types Of Hernia

3. The European Hernia Society classification

• Primary (P), Recurrent (R)
• Lateral (L), Medial (M), Femoral (F)
• The defect size is assumed to be 1.5 cm Thus, a primary direct hernia with a 3 cm defect size is written as PM

4. Gilbert’s classification

• It is based on the defect in the posterior wall (direct hernia) or defect in the internal ring (indirect).
• Depending upon the defect, the suggested repair is given below. However, the basic principles are the same.
• The last two types—type 6 and type 7 are modifications by Robbin.

Algorithm Showing Classification Of Linguinal Hernia

Indirect Hernia

It is a herniation of abdominal contents through the deep ring into the inguinal canal.

Indirect hernia occurs due to persistent processus vaginalis It is the most common type of hernia in the body.

The preformed sac passes through the deep ring, traverses the inguinal canal, and may extend into the scrotum through the external ring.

As it comes into the inguinal canal, it is invested by the following coverings:

1. External spermatic fascia is derived from external oblique aponeurosis.
2. Cremasteric fascia derived from internal oblique.
3. Internal spermatic fascia from fascia transversalis

Types Of Hernia

Parts Of The Hernia

The hernial sac is part of the peritoneum which is dragged into the inguinal canal. The mouth of the sac is in the peritoneal cavity. The neck is the narrowest portion (deep ring). The actual hernial sac has a body and a fundus.

Depending upon the contents, it can be named as follows: Omentum—omentocoele, intestine— enterocoele. Littre’s hernia—hernia containing Meckel’s diverticulum.

It may also contain an ovary or appendix. When part of the wall of the gut is involved, it is known as Richter’s hernia.

Types Of Indirect Hernia

1. Complete hernia (scrotal): When the sac is patent up to the bottom of the scrotum, it is a complete scrotal hernia.
2. Funicular: The processus vaginalis sac is patent up to the root of the scrotum, it is an incomplete indirect hernia.
3. Bubonocoele: Processus vaginalis sac is confined to the inguinal region or the inguinal canal only. Such hernias are seen in young patients.

Types Of Hernia

Coverings of the Indirect Inguinal Hernia from Outside to Inside

1. Skin
2. Two layers of superficial fascia: Fatty and membranous (Camper’s and Scarpa’s fascia respectively).
3. External spermatic fascia is a continuation of the external oblique aponeurosis.
4. Cremaster muscle and fascia, a continuation of the internal oblique.
5. Internal spermatic fascia: Derived from the fascia transversalis.
6. Extraperitoneal fat
7. Peritoneum

Direct Hernia

It is always acquired. It occurs through Hesselbach’s triangle, a weakness in the posterior wall of the inguinal canal (transversalis fascia).

Chronic cough and benign prostatic hypertrophy (BPH) are the common risk factors. Other risk factors mentioned earlier such as smoking also apply here.

Boundaries of Hesselbach’s triangle

• Medially: Lateral border of the rectus abdominis
• Laterally: Inferior epigastric artery
• Below: Inguinal ligament

Coverings of the Direct Inguinal Hernia from Outside to Inside

• Skin
• Two layers of superficial fascia
• External oblique aponeurosis
• Conjoined tendon
• Fascia transversalis
• Peritoneum

Ogilvie Hernia

This is a type of direct hernia wherein the hernial sac appears through a circular defect (congenital) in the conjoined tendon.

Types Of Hernia

Clinical Examination Of A Case Of Hernia

Case Of Hernia History

• Swelling in the inguinal region which is gradually increasing in size. To start with, the swelling disappears on lying down and increases on straining, and walking, later it cannot be reduced (due to adhesions).
• History of dragging pain indicates omentocoele.
• Since the omentum is attached to the stomach above and supplied by T10, the pain is referred to the umbilical region.
• Sudden, severe pain in the hernia, vomiting, and irreducibility indicates an ‘obstructed hernia’.
• History of chronic cough, constipation, and difficulty in passing urine should be asked present, as it may suggest the cause of the hernia.
• History of appendicectomy: Division of the ilioinguinal nerve during appendicectomy may cause denervation of fibers of the right transversus abdominis, which forms a U-shaped ring, resulting in weakness of the abdominal wall.

Clinical Examination: In the standing position

• Inspection (a Model Case of Incomplete Hernia)
• Direct hernia pops out as soon as the patient stands.
• There is a swelling in the inguinal region extending to the root of the scrotum measuring about 6 × 3 cm.

Expansive Impulse On Cough

• Hernia
• Meningocele
• Dermoid cyst with intracranial communication
• Laryngoscope
• Lymphatic cyst in children
• Empyema necessitates it is pyriform in shape.

• Ask the patient to cough—expansile impulse on cough is present. If peristalsis is present, it indicates an enterocoele. Expansile impulse on cough is diagnostic of a hernia.
• The presence of a scar indicates a recurrent herniated scar indicates infection.
• Direct hernia pops out as soon as the patient stands and often it is bilateral.

Expansive Impulse On Cough Palpation

• Inspectory findings should be confirmeSwelling is soft, and gurgles, if it is an enterocoele.
• It may be firm or granular if it is an omentocoele.

1. Ask the patient to cough—an expansile impulse is felt at the root of the scrotum.
2. Getting above the swelling¹ should be done in the standing position.
   • At the root of the scrotum, the spermatic cord is palpated between the finger and the human cases of complete indirect hernia, the spermatic cord cannot be felt as a naked structure because it is covered anterolaterally this is called getting above the swelling not possible (negative).
3. Reducibility—ask the patient to lie down.
   • If the swelling becomes smaller or disappears, it is a hernia (hydrocoele is not reducible).
   • Omentocoele: Initially, the reduction is easy but later, becomes difficult (due to adhesions). If it is difficult to reduce, ask the patient to reduce it.
   • Otherwise, flex and medially rotate the hip and try to reduce it, a method called taxis.
   • If in spite of this, the swelling is not reduced, it is called an irreducible hernia.
4. Internal ring occlusion test (deep ring occlusion test): Reduce the swelling first. Locate the deep ring above the midpoint between the anterior superior iliac spine and the symphysis pubis. Occlude the deep ring with the thumb and ask the patient to cough.
   1. If impulse and swelling are seen, it is a direct hernia because it occurs in Hesselbach’s triangle (medial to deep ring).
   2. If the swelling is not seen, it is an indirect herniated ring occlusion test can be done with the patient in a standing and supine position.
5. Problems of deep ring occlusion test:
   1. If occlusion is not done properly, results may vary.
   2. Pantaloon hernia (Romberg hernia, saddlebag hernia, dual hernia). It is a direct hernia having an indirect component.
6. Zieman’s method: Three-finger methoKeep index finger at the deep ring, middle finger on the posterior wall above and lateral to the external ring, and ring finger at the femoral ring. Now ask the patient to cough.
   1. Depending upon the type of hernia, impulse is felt. It is not necessary to perform this test in incomplete or complete indirect hernias.

Leg raising test or head raising test:

• Weakness of oblique muscles is manifested by Malgaigne’s bulgings above the medial half of the inguinal ligament. It is an absolute indication of hernioplasty.
• Malgaigne’s bulgings indicate weakness of the oblique muscles of the abdominal wall.
• Per abdomen: To rule out any mass (colonic).
• Look for phimosis/stricture urethra: Young patients having urinary complaints with a hernia may be suffering from stricture urethrLift the scrotum and feel for any strictures in the bulbar urethrRetract skin of prepuce and rule out phimosis.
• Per rectal examination should be done in elderly patients to rule out prostatic enlargement.
• Examination of the respiratory system is done to rule out chronic bronchitis, tuberculosis, etc.

Clinical Examination of Hernia in a Child

Swelling may not be visible at first as it may be covered by a thick pad of fat. Examine when a child strains (cries), or after a child’s play (jumping, etc.). Examine the root of the scrotum—may find hernial sac (thickening).

Gornall’s test: By gentle compression on the child’s abdomen (hold the child on its back), a hernia may become apparent.

Invagination test is almost impossible. Hence, it is better not to do it.

Diagnosis (One Example)

Right side, indirect, incomplete, uncomplicated, reducible omentocoele. Differences between direct and indirect hernia and for differences between hernia and hydrocoele.

Differential Diagnosis Of A Groin Swelling

Groin refers to the junction of the lower abdomen with the thigh. Hence, swellings in the inguinal region and upper thigh (femoral region) close to the inguinal ligament are included under groin swellings.

1. Inguinal hernia.
2. Femoral hernia: The main sac is below and lateral to the pubic tubercle.
3. Vaginal hydrocoele: Fluctuation and transillumination tests are usually positive and getting above swelling is possible. (Please note that in infantile hydrocoele and hydrocoele en bisac, getting above swelling is not possible).
4. Retractile testis: It can present as a firm swelling in the inguinal region. The scrotum is empty.
5. Saphena varix: The patient can present with a swelling in the thigh. Swelling is usually about 2.5 cm below the pubic tubercle. A swelling that disappears on the elevation of the leg is characteristic of a swelling of venous origin.
6. Funiculitis: Funiculitis can occur with or without acute epididymorchitis. Severe pain in the inguinal region, tender swelling, and high-grade fever with chills and rigors are characteristics of the cord being thickened and swelling is not reducible.
7. Inguinal lymphadenitis: Pain and nodular swelling below the inguinal ligament is a feature. It is not reducible and some source of infection in the lower limb is usually present.
8. Lipoma of the cord: It presents as a soft, lobulated but irreducible swelling in the inguinal region.

Differential Diagnosis Of A Groin Swelling Investigations

Hernia is a clinical diagnosis. Except for small direct hernias in very elderly patients above 80 years, almost all inguinal hernias should be treated in the vast majority of cases, no investigations are required specific to the diagnosis However, in appropriate cases, imaging can be done.

• The first advice for a smoker with a hernia is to stop smoking at least 3 to 6 weeks before surgery. If a patient is a high-risk patient, he should stop smoking at least 6 months before surgery.

1. Ultrasound: In apparently occult cases wherein the patient has groin pain but clinically not evident, ultrasound can detect a sac—however it is operator-dependent. In large hernias including sliding hernias, ultrasound can identify structures such as the urinary bladder or colon, thus giving useful information to the surgeon.
   • Ultrasound is also useful in cases of postoperative swelling in the groin to rule out hematoma/seroma/recurrence.
   • Hernia is a clinical diagnosis. If you are asked to give one investigation to confirm a hernia (maybe in early cases), it is ultrasound.
2. Computed tomography (CT) scan is ideal in cases of giant hernias, sliding hernias, or special types such as obturator hernias, perineal hernias, etc.
3. Routine investigations such as complete blood picture (CBP) and urine examination are done. In elderly patients, chest X-ray, electrocardiography, or even pulmonary function tests may be necessary. Patients with urinary complaints are evaluated for prostatic enlargement and stricture urethra.
4. Magnetic resonance imaging (MRI): Ideal in sportsmen who complain of groin pain, to differentiate between hernia, to rule out muscle sprain, or any other orthopedic disorders.

Preoperative Preparation

• A patient with chronic bronchitis and bronchial asthma should be properly treated with bronchodilators, antibiotics, and mucolytic agents, and cigarette smoking should be stopped at least 3 weeks before the surgery.
• Elderly patients with bilateral hernia mostly suffer from benign prostatic hypertrophy. Prostatectomy should be considered first followed by repair of hernia, in such cases. A recent history of constipation and the appearance of a hernia should arouse the suspicion of carcinoma colon. Investigate by colonoscopy/fibreoptic sigmoidoscopy before the treatment of hernia.
• Often patients are smokers with chronic obstructed pulmonary diseases.
• Young adults with difficulty in passing urine may have a stricture urethrThey should undergo proper treatment for the stricture. Now it is rare to find a patient with a hernia having a stricture urethra

Muscles Of The Anterolateral Abdominal Wall—Oblique Muscles

• The anterolateral abdominal wall is made up mainly of muscles. On either side of the midline, there are four large muscles. These are the external oblique, the internal oblique, the transversus abdominis, and the rectus abdominis.
• Two small muscles, the cremaster, and the pyramidal are also present. The external oblique, the internal oblique, and the transversus abdominis are large flat muscles placed in the anterolateral part of the abdominal wall.
• Each of them ends in an extensive aponeurosis that reaches the midline. Here the aponeuroses of the right and left sides decussate to form a median band called linea alb
• The rectus abdominis runs vertically on either side of the line It is enclosed in a sheath formed by the aponeuroses of the flat muscles named above.
• Tendinous intersections—rectus sheath hematoma will be confined within the sheaths as it is prevented from spreading due to tendinous intersections.

Precautions during Surgery

• Nerve supply—lower six thoracic and first lumbar nerves. They enter the rectus sheath laterally. In cases of paramedian incisions, after opening the anterior rectus sheath, the rectus should be retracted laterally to define and incise the posterior rectus sheath.
• Blood vessels run within the rectus sheath. The rupture of the inferior epigastric artery is a known entity resulting in a hematoma below the umbilicus.
• Differential diagnosis includes a Spigelian hernia.
• Weak muscles—interstitial hernias—prune-belly syndrome: A partial or complete lack of abdominal muscles. There may be wrinkly folds of skin covering the abdomen. An undescended testicle in males can also be a problem.

Management Of Massive Abdominal Wall Hernias

• Massive or giant ventral hernia poses a challenge to the surgeon in appropriate management and to the patient by incapacitating him to live with poor quality of life.
• There is no consensus on standard definition but most surgeons agree that giant or massive ventral hernias are those having more than 10 cm defect size with loss of domain.

Giant ventral hernias can arise due to:

• Primary hernias are left unattended for a long time.
• Recurrence after one or more failed hernia repairs.
• Result of open abdomen or laparostomy.
• The contents in such cases may be multiple bowel loops or other viscera that protrude outside the abdominal cavity causing a “second abdomen” due to muscle retraction on either side of the defect.

In such a clinical scenario, the standard repair becomes an impossible proposition.

• Closing the abdomen with tension is not an option because it causes cardiorespiratory embarrassment and later, lateral recurrence of hernia due to disruption of linea semilunaris.
• The most critical issue in the management is to optimize these patients before posting them for surgery and to do good counseling about the difficulties involved in such cases.
• The patient needs a thorough clinical examination not only of the hernia but rest of the abdomen and the whole body.
• Putting the abdominal muscles into contraction by head raising and leg raising test, asking the patient to cough in a lying down position, and again examination in a standing position will give a fair knowledge of the loss of domain, reducibility, and defect size.
• Loss of domain (LOD) means a significant amount of viscera has herniated through the abdominal wall into the sac and more viscera may be outside than inside the abdominal cavity.
• Imaging by CT scan is essential to assess the defect size, status of viscera, abdominal wall musculature, and any other intra-abdominal pathology.
• If the surgeon is inexperienced or the center is not well equipped to manage such patients, then the patient needs to be referred to a higher center.
• Such patients should stop smoking for at least 3 months prior to surgery and any remote infections should be treated
• Diabetic patients need good glycemic control with HbA1c around 6.5% and they should not have any chronic liver disease.
• If there are any precipitating factors such as chronic cough, constipation, or difficulty in passing urine, they should be corrected before surgery.
• Incentive spirometry and breathing exercises must be commenced prior to planned surgery. If the patient is morbidly obese, the BMI needs to be reduced to around 35 kg/m2.
• Some patients will require bariatric surgery (e.g. sleeve gastrectomy) as a first step and later definitive surgery for ventral hernia once the patient attains acceptable BMI.
• There are two methods to optimize patients with loss of domain so that the capacity of the abdominal cavity increases and they do not develop cardiorespiratory embarrassment when the contents are pushed in during the repair of ventral hernia. Botulinum toxin (type A) injection to abdominal wall muscles.

2. Preoperative progressive pneumoperitoneum.

• Botulinum toxin injected 4 weeks prior to surgery under ultrasound guidance on either side to abdominal wall muscles in the anterior axillary line will cause temporary flaccid paralysis making midline closure possible.
• Similarly, progressively distending the abdomen with air for 10 to 14 days through an indwelling catheter inserted into the abdominal cavity will facilitate the reinsertion of bowel loops into the abdominal cavity.
• Once the abdominal cavity is sufficiently expanded by the above methods and contents from the sac have returned to the abdominal cavity, the patient is ready for a definitive procedure. This can be confirmed by a CT scan.
• The aim of surgery is to correct the abdominal wall weakness by moving tissues medially by redistributing the abdominal muscles.
• A dynamic and durable repair is obtained with midline closure and reinforcement of the abdominal wall with a large polypropylene mesh.
• Every precaution to prevent mesh infection is mandatory. The most commonly performed surgery in massive ventral hernias is the open posterior component separation technique (PCST) also known as transverse abdominal muscle release (TAR) which may be done on one side or on both sides for a tension-free midline closure.
• This can also be performed by robotic or laparoscopic (eTEP-TAR) methoAnterior component separation technique (ACST) is another way to achieve midline closure in massive ventral hernias.
• During emergency situations such as obstruction or gangrene, a staged repair strategy is adopted to deal with the emergency in the first surgery and plan for hernia repair after a few months.
• To conclude, the management of massive or giant ventral hernia requires a carefully planned approach with adequate optimization prior to surgery and a tension-free midline closure by component separation technique with reinforcement by a nonabsorbable mesh to achieve good results.

Epigastric Hernia

• It is also called fatty hernia of the linea
• This type of hernia occurs in the epigastrium through the linea alba which extends between the xiphoid process and umbilicus.

Precipitating Factors

• Sudden straining or heavy exercise results in the tearing of a few fibers of the linea alba and is responsible for precipitating an epigastric initially there is a small protrusion of the extraperitoneal pad of fat.
• Rarely, if it enlarges, it is due to the dragging of the peritoneal saThe opening is very narrow. Hence, the hollow viscus cannot enter the saDiastasis of rectus muscles which results in a wide linea alba and can also precipitate an epigastric hernia.

Clinical Features

• Common in muscular men, and manual laborers.
• Typically the swelling is situated in the upper abdomen midway between the xiphoid process and the umbilicus. Often, it contains only an extraperitoneal protrusion of fat.
• An expansile impulse on cough is rare. Dull aching pain is due to the fatty contents which are partially strangulated
• However, tenderness is an important feature of epigastric hernia cases associated with peptic ulcer disease. On head-raising, it becomes more prominent.

 

Peculiarities of Epigastric Hernia

• Common in muscular men
• The hernial sac is uncommon
• A hollow viscus in the sac is rare
• Impulse on cough is rare
• Reducibility is rare
• Tenderness is an important feature

Rare External Hernias Interparietal Hernia

• It is also known as interstitial hernia
• Basically, they are inguinal hernias. However, the processus vaginalis sac instead of following the normal route into the scrotum, traverses between various layers of the abdominal wall (parietes) resulting in interstitial hernias.
• Patients with Down’s syndrome and prune-belly syndrome are commonly affected.

Rare External Hernias Interparietal Hernia Types

1. Preperitoneal: In this variety, the hernial sac lies between the transversalis fascia and peritoneum. It is seen in about 20% of patients. The sac is like a small diverticulum.
2. Interparietal: It is also called intermuscular type. It is the commonest variety wherein the sac passes between the external oblique and internal oblique muscles. The swelling caused by the hernial sac causes discomfort to the patient. Sometimes, this can be a bilocular sac.
3. Extraparietal: It is also known as inguinal-superficial variety. In this variety, the hernial sac passes exterior (superficial) to the external oblique aponeurosis beneath the superficial fascia of the abdominal wall.
   • It is commonly associated with undescended testis or ectopic testis. The majority of such cases present features of intestinal obstruction.
   • They are treated by identifying the sac, excision followed by closure of the defect, or repair by using nonabsorbable sutures.