Strangulation of paraumbilical hernia is frequent which justify operation in nearly all cases, from the image above the fibrous rigid linea alba (black arrow) creates a narrow neck with a rigid edge that makes strangulation likely, in addition sometimes in large hernias loculations due to omental adhesions cause strangulation in a knuckle of intestine in an otherwise soft and non tender hernial sac.
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This is a polypropylene mesh used for hernioplasty, this provides structural support to a weak defect, it gained widespread popularity especially with inguinal hernias (Lichtenstein tension-free hernioplasty), it can be used for recurrent paraumbilical hernias or those with very large defect.
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Mayo's operation, indicated for small defects on paraumbilical hernias, the operation simply proceed with transverse elliptical incision near the umbilicus, the subcutaneous fat is dissected to reveal the anterior rectus sheath and the neck of the hernia which is incised, the contents are delt with appropriately and then the sac is dissected out and the peritoneum sutured, then the defect is strengthened with overlapping of the aponeuroses on each side of the umbilicus and fixed with sutures the overlap should be 5 to 7.5 cm.
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Paraumbilical hernia
◼️It is protrusion of a hernial sac in a weak point at the linea alba above or sometimes below the umbilicus.
◼️It can attain massive size.
◼️It is 5 times more common in females.
◼️Obesity, flabbiness of abdominal muslces and repeated pregnancy are important aetiologic factors.
◼️The neck of this hernia is remarkably narrow when compared to the size of the sac or volume of its contents, thus it is liable for strangulation and require operation.
◼️In longstanding cases the sac may become lobulated due to omental adhesions rendering it irreducible, in addition intertrigo due to friction of adjacent skin surfaces and trophic ulcers are troublesome complications.
◼️Dragging pain due to traction and transient intestinal colic due to partial intestinal obstruction may occur.
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#Surgery
◼️It is protrusion of a hernial sac in a weak point at the linea alba above or sometimes below the umbilicus.
◼️It can attain massive size.
◼️It is 5 times more common in females.
◼️Obesity, flabbiness of abdominal muslces and repeated pregnancy are important aetiologic factors.
◼️The neck of this hernia is remarkably narrow when compared to the size of the sac or volume of its contents, thus it is liable for strangulation and require operation.
◼️In longstanding cases the sac may become lobulated due to omental adhesions rendering it irreducible, in addition intertrigo due to friction of adjacent skin surfaces and trophic ulcers are troublesome complications.
◼️Dragging pain due to traction and transient intestinal colic due to partial intestinal obstruction may occur.
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Umbilical hernia
◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.
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#Surgery
◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.
#Hernia
#Surgery
Enlargement of femoral lymph nodes Vs femoral hernia
◼️Presence of enlarged lymph nodes elsewhere helps to differentiate between this condition and femoral hernia.
◼️If Cloquet lymph nodes alone are enlarged (thick black arrows) it may be impossible to differentiate between it and femoral hernia,, inless there is other clues such as infected wounds or abrasions in the corresponding limb or perineum.
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◼️Presence of enlarged lymph nodes elsewhere helps to differentiate between this condition and femoral hernia.
◼️If Cloquet lymph nodes alone are enlarged (thick black arrows) it may be impossible to differentiate between it and femoral hernia,, inless there is other clues such as infected wounds or abrasions in the corresponding limb or perineum.
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Saphena Varix Vs femoral hernia
◼️Saphena varix is enlargement of the terminal end of long saphenous vein.
◼️It is differentiated from femoral hernia by :
¶ Saphena varix is usually associated with other signs of varicose veins.
¶ Saphena varix usually disappear completely while the patient lies flat, while a femoral hernia will usually be still palpable.
¶ A fluid thrill is felt with the saphena varix when the patient cough or when the long saphenous vein is tapped below the varix.
¶ Saphena varix may be associated with a venous hum which is heard when the stethoscope is placed on the varix.
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◼️Saphena varix is enlargement of the terminal end of long saphenous vein.
◼️It is differentiated from femoral hernia by :
¶ Saphena varix is usually associated with other signs of varicose veins.
¶ Saphena varix usually disappear completely while the patient lies flat, while a femoral hernia will usually be still palpable.
¶ A fluid thrill is felt with the saphena varix when the patient cough or when the long saphenous vein is tapped below the varix.
¶ Saphena varix may be associated with a venous hum which is heard when the stethoscope is placed on the varix.
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Femoral Vs inguinal hernia
◼️The NECK of an inguinal hernia always emerge from the external inguinal ring whether it is direct or indirect, therefore the neck will be above and medial to the most medial end of the inguinal ligament at its attachment to the pubic tubercle.
◼️The neck of a femoral hernia always pass through the femoral canal, which will be below and slightly lateral to the pubic tubercle.
◼️Applying pressure on the external inguinal ring and asking the patient to cough is another way to differentiate, in femoral hernia a cough impulse is exerted when the pressure is applied and vice versa.
◼️The fundus of a femoral hernia may pass in the path of least resistance and may overlie the inguinal ligament.
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◼️The NECK of an inguinal hernia always emerge from the external inguinal ring whether it is direct or indirect, therefore the neck will be above and medial to the most medial end of the inguinal ligament at its attachment to the pubic tubercle.
◼️The neck of a femoral hernia always pass through the femoral canal, which will be below and slightly lateral to the pubic tubercle.
◼️Applying pressure on the external inguinal ring and asking the patient to cough is another way to differentiate, in femoral hernia a cough impulse is exerted when the pressure is applied and vice versa.
◼️The fundus of a femoral hernia may pass in the path of least resistance and may overlie the inguinal ligament.
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Pathology of femoral hernia
◼️This device is called a retort, it is used in chemisty for distillation of fluids, water is placed in the distended part and heated, so on water will be dripping out of the funnel part,, it is the best example to describe a femoral hernia.
◼️The femoral hernia descend through the inelastic rigid femoral canal (corresponding to the funnel of retort "black arrow") and emerge from the saphenous opening.
◼️Once it bypass the saphenous opening the hernia distend in the loose areolar tissue of the groin (corresponding to the distended part of the retort "white arrow").
◼️Note that sometimes the distension is considerable that the bulbous extremity of the hernia lie above the inguinal ligament.
◼️The funnel of the retort (black arrow) reflect how the hernia is so narrowed at the femoral canal, this is why femoral hernias are the most liable hernia to strangulate.
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◼️This device is called a retort, it is used in chemisty for distillation of fluids, water is placed in the distended part and heated, so on water will be dripping out of the funnel part,, it is the best example to describe a femoral hernia.
◼️The femoral hernia descend through the inelastic rigid femoral canal (corresponding to the funnel of retort "black arrow") and emerge from the saphenous opening.
◼️Once it bypass the saphenous opening the hernia distend in the loose areolar tissue of the groin (corresponding to the distended part of the retort "white arrow").
◼️Note that sometimes the distension is considerable that the bulbous extremity of the hernia lie above the inguinal ligament.
◼️The funnel of the retort (black arrow) reflect how the hernia is so narrowed at the femoral canal, this is why femoral hernias are the most liable hernia to strangulate.
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Surgical anatomy of the femoral ring
◼️Anteriorly it is bound by the inguinal ligament.
◼️Medially it is bound by the Lacunar ligament (Gimbernant's ligament).
◼️Posteriorly it is bound by the ileopectineal ligament (Astley cooper's ligament) and the pubic bone and fascia over the pectineus muscle.
◼️Laterally it is bound by a thin membrane seperating it from the femoral vein.
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◼️Anteriorly it is bound by the inguinal ligament.
◼️Medially it is bound by the Lacunar ligament (Gimbernant's ligament).
◼️Posteriorly it is bound by the ileopectineal ligament (Astley cooper's ligament) and the pubic bone and fascia over the pectineus muscle.
◼️Laterally it is bound by a thin membrane seperating it from the femoral vein.
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The box above highlights the essential aspects of femoral hernias.
Femoral hernias out of all hernias, are the most liable for strangulation mainly because of the narrowness of the neck "femoral canal is 1.25 cm only at its base which is directed up creating a funnel" and also because of the rigidity of the femoral ring.
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Femoral hernias out of all hernias, are the most liable for strangulation mainly because of the narrowness of the neck "femoral canal is 1.25 cm only at its base which is directed up creating a funnel" and also because of the rigidity of the femoral ring.
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Reduction en masse
Reduction-en-masse means reduction all together, it refer to a complication of manual reduction of a hernia in which the entire hernial mass including the contents and the sac and the neck are reduced back to the abdomen, so practically the strangulation is not relieved.
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Reduction-en-masse means reduction all together, it refer to a complication of manual reduction of a hernia in which the entire hernial mass including the contents and the sac and the neck are reduced back to the abdomen, so practically the strangulation is not relieved.
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Femoral sheath and femoral canal
◼️The femoral sheath lies in the femoral triangle and it is a sleeve of fascia that is continuous superiorly with the transversalis fascia.
◼️It is divided by septa into compartments.
◼️The most medial compartment is called the femoral canal.
◼️The femoral canal is 1.25cm long and 1.25 cm width at its base which is directed upwards.
◼️The femoral canal contains lymphatic vessels and lymph nodes of Cloquet.
◼️It starts from the femoral ring and ends at the saphenous openings.
◼️From above it is closed by a septum called septum crurale and from below it is closed by the cribriform fascia.
◼️The septum crurale is pierced by lymphatics and is a potential point of weakness making the femoral canal the site of femoral hernias
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◼️The femoral sheath lies in the femoral triangle and it is a sleeve of fascia that is continuous superiorly with the transversalis fascia.
◼️It is divided by septa into compartments.
◼️The most medial compartment is called the femoral canal.
◼️The femoral canal is 1.25cm long and 1.25 cm width at its base which is directed upwards.
◼️The femoral canal contains lymphatic vessels and lymph nodes of Cloquet.
◼️It starts from the femoral ring and ends at the saphenous openings.
◼️From above it is closed by a septum called septum crurale and from below it is closed by the cribriform fascia.
◼️The septum crurale is pierced by lymphatics and is a potential point of weakness making the femoral canal the site of femoral hernias
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#Femoral_Triangle
◼️It is a wedge shaped depression formed by the muscles of the upper thigh at the junction between the anterior abdominal wall and lower limb.
◼️The base of the triangle is the inguinal ligament.
◼️Medial border is the medial margin of adductor longus.
◼️Lateral border is the medial margin of sartorius muscle.
◼️Floor of the triangle is formed medially by the pectineus muscle and adductor longus,, laterally it is formed by the iliopsoas muscle descending from the abdomen.
◼️The apex is continuous with a fascial canal called Adductor canal which pass posteromedially down the thigh and ends in a hole in adductor magnus muscle to open on the popliteal fossa.
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◼️It is a wedge shaped depression formed by the muscles of the upper thigh at the junction between the anterior abdominal wall and lower limb.
◼️The base of the triangle is the inguinal ligament.
◼️Medial border is the medial margin of adductor longus.
◼️Lateral border is the medial margin of sartorius muscle.
◼️Floor of the triangle is formed medially by the pectineus muscle and adductor longus,, laterally it is formed by the iliopsoas muscle descending from the abdomen.
◼️The apex is continuous with a fascial canal called Adductor canal which pass posteromedially down the thigh and ends in a hole in adductor magnus muscle to open on the popliteal fossa.
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