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Ventral Hernia


Presentation

A detailed medical history can reveal the natural course of the disease and whether the defect is congenital or acquired. A through physical examination will also be an invaluable tool in the diagnosis. Patient may need to be examined in both upright and supine position for better results.

Hernias will initially present as a bulge in the abdomen as with ventral hernia or a bulge in the scrotal sac in the case of inguinal hernia. Palpation and probing of the hernia sac may reveal its direct or indirect nature.

Patients may present with large lumps in the ventral abdomen where the visceral organs seen may give one a clue on the herniating organ and how to manage it.

Incarcerated hernia will present with swelling, pain on palpation and the inability to manipulate the hernia sac. The associated systemic signs of fever, nausea and vomiting may be suggestive of a more urgent case of intestinal strangulation which merits immediate surgery.

Spontaneous Hemorrhage
  • The authors report a case of severe spontaneous hemorrhage in a patient who underwent surgical repair of an upper umbilical ventral hernia with placement of a polypropylene mesh.[ncbi.nlm.nih.gov]
Neglect
  • Neglected incarcerated hernia may lead to bowel obstruction, bowel rupture and peritonitis which are all life-threatening medical conditions.[symptoma.com]
  • As with the exploration of the bilateral inguinal region, detecting another defect and correcting it, at the same time, avoids neglected hernias, which are diagnosed subsequently as incisional hernias and require subjecting the patient to a new surgery[elsevier.es]
Flaccid Paralysis
  • All patients were treated preoperatively with both Botulinum Toxin A (BTA) injections to the lateral abdominal wall muscles to confer flaccid paralysis, and short-term PPP to passively expand the abdominal cavity.[ncbi.nlm.nih.gov]

Workup

Since the diagnosis of ventral hernia can be easily clinched by proper history taking and physical examination the need for laboratory workups may not no longer be necessary for it may only yield non-specific results.

Imaging studies like CT and MRI may only be necessary when determining the contents of the hernia sac within the abdomen or in determining the extent of the intestinal strangulation, otherwise it isn’t that necessary [7].

Laboratory workups may only be ancillary and may be used to rule out other differential causes. The urinalysis may rule out the pain of inguinal hernia against an impending urinary tract infection.

Culture from infected wound or stump may identify the pathogenic organism infecting the site. Complete blood count will not be specific but will show leukocytosis. Serum electrolytes will show the hydration status of the patients for proper management.

Dyslipidemia
  • BACKGROUND: Metabolic syndrome (MetS) entails the simultaneous presence of a constellation of dangerous risk factors including obesity, diabetes, hypertension, and dyslipidemia.[ncbi.nlm.nih.gov]

Treatment

The main approach in the treatment of ventral hernia is surgical reduction which may require analgesia and sedation to lower the intraabdominal pressure [8].

The Single Port Access (SPA) prosthetic repair of incisional hernia gives promising results with rare events of recurrence [9]. Surgeons ascertain initially whether the hernia is already strangulated or incarcerated which will greatly influence the methods of surgical procedures and the morbidity of the case. Ventral hernia may be approached with minimal incisions like those with laparoscopic surgical procedures but risk factors should be identified like increased Body Mass Index, history of previous repair and size of hernia to prevent any complication during the surgery [10].

Inguinal hernias will benefit from the surgical repair (Bassini repair) of the weakened wall using synthetic meshes to prevent recurrence of the hernia.

Less invasive approach for topical treatment of ventral hernias employ the use of cauterization in removing the granuloma, scarring the sac of a giant omphalocele with use of agents like povidone iodine will reduce infection, and progressive compression dressing which locally prevents further evisceration of the hernia. Postoperative patients will be regularly monitored to avert the recurrence of the ventral hernia.

Prognosis

The prognosis of all abdominal hernia is greatly influenced by the early detection and treatment of the hernia. Morbidity and mortality rate also varies directly with the size of the herniated mass and the size of the defect of the abdominal hernia.

Morbidity correlates closely with the associated complications of the ventral hernia. Neglected incarcerated hernia may lead to bowel obstruction, bowel rupture and peritonitis which are all life-threatening medical conditions. The manner and conduct of the surgical operations may also influence the prognosis of the disease where iatrogenic subcutaneous emphysema and surgical site infections can also occur and increases morbidity.

Complications

There are a number of possible complications of an abdominal hernia, the following are the most common ones:

  • Incarceration or strangulation of the trapped bowel loop: When the herniated viscera is trapped within the hernia ring, bowel obstruction and infarction may occur leading to lethal consequences.
  • Hernia recurrence: Even with surgical repair, hernia may recur in the same site or proximal to the site of repair. Ventral hernia usually recurs within 2 years from the first repair operation [6].
  • Iatrogenic injury: Subsequent hernia repair may inadvertently injure other organs in the process like the urinary bladder, vas deferens, and the intestines.
  • Wound infection: Post-operative surgical site infection is common especially with poor wound care after the patient is discharged from the hospital. 
  • Intestinal obstruction: Complete obstruction may lead to rupture and peritonitis while partial obstruction may cause malnutrition and growth failure.

Etiology

Incisional hernia occurs at the site of a former abdominal surgery because it is weakened by several factors. Any strain to the abdominal walls like the Valsalva in constipated defecation, chronic coughing and lifting of heavy weights can propagate the herniation in the abdominal wall.

Pregnancy can inherently stretch and aggravate the abdominal hernia. An infected surgical wound can weaken and result to evisceration if the wounds dehisce. Diabetics and chronic steroid users are prone to surgical site infection and ventral hernia.

Epidemiology

In the United States, over 1 million abdominal surgeries are performed to repair all forms of ventral hernia. More than three-fourths of these cases are inguinal type of hernia [1]. There is a male predominance for inguinal hernia with a 7:1 male to female ratio with more than half of the cases being indirect in in nature [2]. Inguinal hernia has a predisposition to the left side of the inguinal area.

Females are more prone to incisional hernia compared to men [3]. Congenital umbilical hernia often presents as ophalocele (herniated stump in navel) in the newborn. The incidence of omphalocele has currently risen with a prevalence rating of 1-2.5 cases per 5000 live births [4].

Older patients are prone to direct inguinal hernia due to the subsequent wall weakness. Premature infants born before 32 weeks of gestation have a 13% incidence of indirect hernia which are observable in the first month of life [5].

Bowel loops that protrude in the abdominal wall may be trapped and constricted causing a painful surgical emergency known as incarceration. Infants less than 6 months has twice the risk of incarcerated hernia than their older counterparts.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of incisional hernia lies on the breakdown of the fascial closure of the abdominal surgical wound. The incidence of recurrence in incisional hernia is relatively high, ranging from 20-45%.

Umbilical hernia is a result of the failure of the umbilical ring to physiologically close. Children with congenital problems with collagen synthesis like Ehler-Danlos Syndrome and osteogenesis imperfecta have an increased risk for umbilical hernia.

Spigelian hernia occurs due to a defect in the spigelian fascia by the lateral edge of the rectus abdominis muscle (abdominal muscles).

The paralysis of the abdominal internal ring and the high lying abdominis aponeurosis may fail to prevent herniation of visceral organs in the inguinal ring causing the inguinal hernia.

Prevention

Ventral hernia may appear at birth which should always be given attention to prevent incarceration of the herniated organ.

Abdominal hernia may be prevented if risks are identified early in the course of the disease. Patients identified with weakness in the abdominal wall should be restricted to strain or lift heavy objects.

Constipation may be prevented with the use of laxatives and chronic coughing may be controlled with antitussive preparations.

Patient who had prior surgical hernia repair should apply proper wound care to prevent infections and wound dehiscence. A regular visit to the surgeon to monitor hernia progression can be very beneficial.

Summary

Ventral hernia is any abnormal protrusion in the abdominal wall caused by a weakened point in the muscles or tissues due to prior incisions or defect. Because of its frequent occurrence in the incisional site, it is also referred to as an incisional hernia.

Protrusion in the umbilical area is sometimes coined as an umbilical hernia, a type of ventral hernia that may not precede any abdominal surgery. Abdominal protrusions in the ventral (anterior abdomen) is oftentimes caused by an intestinal loop or any abdominal tissue that makes its way through the wall defect.

Abdominal hernia with encroachment beneath rib cage at epigastrium is called epigastric hernia while hernia which develops within the colostomy or jejunostomy stoma is known as stomal hernia. Inguinal hernia are abnormal encroachment in the inguinal area or groin which occur more commonly in men.

Patient Information

Ventral hernia is a bulging of the belly wall caused by a weakened point in the muscles or tissues.

Patients with high risk of hernia should avoid all occasions of straining like lifting of heavy loads. Medical support devices like body truss and corsets may support the abdominal wall if there are abnormal masses that herniate in the ventral abdomen.

Athletes with high risk to inguinal hernia must wear groin supporters. Any suspicious lumps in the abdominal wall should be promptly brought for surgical consultation and immediate intervention.

References

Article

  1. Manthey DE. abdominal hernia reduction. In: Clinical Procedures in Emergency Medicine. Of of 2003. 
  2. Katz DA. Evaluation and management of inguinal hernias and umbilical. Pediatr Ann. Dec. 2001, 30 (12): 729-35. 
  3. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. April 2008, 45 (4): 261-312. 
  4. Scherer LR 3rd, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. Dec. 1993, 40 (6): 1121-31. 
  5. Brandt ML. Pediatric hernias. Surg Clin North Am. February 2008, 88 (1): 27-43, vii-viii. 
  6. Singhal V, Szeto P, VanderMeer TJ, B. Ventral hernia repair Cagir: outcomes change with long-term follow-up. JSLS. 2012; 16 (3): 373-9 
  7. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. April 2008, 45 (4): 261-312. 
  8. Inguinal hernia reduction S. Smith. In:. C. King, Henretig FM, eds . Procedures Textbook of Pediatric Emergency 2nd ed Philadelphia, PA :. Lippincott Williams and Wilkins; 2008: 840-847 / 87th
  9. Bucher P, Pugin F, Morel P. Single-port access prosthetic repair for primary and incisional ventral hernia. toward less parietal trauma . Surg Endosc 2011; 25 (6): 1921-5 (ISSN: 1432-2218)
  10. Jenkins ED, Yom VH, Melman L, Pierce RA, Schuessler RB, Frisella MM, Christopher Eagon J, Michael Brunt L, Matthews BD. Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study. Surg Endosc. 2010; 24 (8): 1872-7 (ISSN: 1432-2218)

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Last updated: 2019-07-11 22:06