EPIGASTRIC HERNIA FATTY HERNIA OF LINEA ALBA Incidence

EPIGASTRIC HERNIA & FATTY HERNIA OF LINEA ALBA

Incidence: Common in adult males and females. Pathology: • Protrusion of a lobule of extraperitoneal fat through a defect in the interlacing fibers of the linea alba. It may be single or multiple • It has no sac, when it enlarges it may have a small conical one with a piece of omentum as contents changing into epigastric hernia • The coverings are skin and subcutaneous tissue Complications: Rare Clinical Picture: • A midline supraumbilical small sized swelling, occasionally tender, gives an impulse on cough. It is rarely reducible • The piece of omentum included in the hernia may pull on the stomach, giving rise to dyspeptic symptoms very much simulating a peptic ulcer

Treatment: ØSmall hernia with no sac: Excision of the fat lobule and repair of the defect in the linea alba ØLarge hernia: Mayo's operation as for P. U. H. which is called with recurrence so better for hernioplasty

DIVARICATION OF THE RECTI

1. Babies: Above the umbilicus, self limited with development 2. Adults: Very common in Egypt, with association of Bilharzial hepatosplenomegaly syndrome. Also common in multiparous females Pathology: Linea alba stretched into a weak wide fibrous sheet, with the recti separated and attenuated Clinical Picture: 1. On straining a bulge appears between the recti 2. The gap is felt by the examining fingers when the abdomen relaxes

Treatment: 1. Babies: Abdominal belt, the condition is self limited 2. Old friable patients: Abdominal corset 3. Fit adults: a. Correct the cause first b. Operation: Vertical Mayo's repair: Using a longitudinal incision, the widened linea alba and peritoneum are opened longitudinally in the midline The 2 sides are overlapped by mattress sutures and the skin is closed with a drain

Keel's Repair: Indications: All hernia of the middle line with: a. Wide neck. b. Reducible contents. c. Not loculated • Using a longitudinal incision the peritoneum is identified and dissected down to the neck Without opening the sac it is pushed back in the abdomen, and by a series of inverting sutures the edges of the defect are closed • Viewed in cross section this repair looks like the Keel of a boat

Spigelian Hernia • This is a hernial protrusion through the aponeurosis of the transversus abdominis (Spigelian fascia) which forms the lateral border of the rectus sheath (linea semilunaris) • The sac lies deep to the external oblique aponeurosis and so it often remains unnoticed until strangulation occurs Treatment should consist of early operation since strangulation is a common complication

Incisional Hernia A hernial protrusion through a post-operative scar may be due to: 1. Pre-operative causes: (i) poor general condition due to old age, malnutrition or malignant disease; (ii) weak abdominal musculature due to debility or repeated pregnancies, or (iii) high intra-abdominal pressure due to obesity, chronic cough or straining 2. Faulty operative technique: (i) division of muscles, (ii) injury to nerves; or (iii) inadequate suturing 3. Post-operative causes: (i) post-operative distension, coughing or straining; (ii) wound complications, e. g. haematoma, infection and burst abdomen; or (iii) hurried convalescence without adequate support to the wound

Clinical Features: The hernia usually appears within a few weeks or months after operation, and may affect the whole or part of the scar. It often steadily increases in size and may strangulate Treatment: If operation is contraindicated because of old age, excessive obesity or poor general condition, an abdominal belt may be used. In all other cases, operation should always be advised, particularly when the hernia is large and situated in the lower abdomen. Depending on the size of the defect four methods of repair are available:

1. Anatomical reconstruction • Is employed if the defect is small. After removal of the sac, all scar tissue is excised and the layers of the abdominal wall are defined and approximated separately 2. The keel operation • Is adequate for vertical incisional hernias The technique is the same as for divarication of the recti

3. Cattell’s “five-layer” repair • Is a simple and effective method. Starting within the Opened sac, the peritoneum and underlying fibrous edges of the defect are approximated with a continuous interlocking suture of strong chromicized catgut • The sac is then excised 2 cm. distal to the suture and its cut edges are united with a continuous catgut suture • An elliptical incision is made 2 cm. lateral to the previous suture line, and the medial flaps are approximated • The muscles on either side are now drawn together. by interrupted stitches, and then the lateral aponeurotic flaps are united over the muscles with stainless steel or silk sutures

4. Hernioplasty by prosthetic mesh, skin grafting or metallic transplant may be necessary when the defect is very wide