-Portal vein consists of SMV and splenic vein.

-It begins behind the head of pancreas and in front of IVC, ends at porta
-hepatis.
-About 3inch length.
-About 0.8-1.2 cm diameter.


Direct tributaries:
Portal vein drains the whole. intra-abdominal alimentary tract and anterior abdominal wall:

- Left and right gastric veins.
-Small pancreatic & duodenal veins.
-Para-umbilical veins into left branch of portal vein.
- Splenic vein.
-SMV.
-Cystic vein.

Pressure: 10 - 20 cmH2O (7 - 11 mmHg).

#Surgery

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.

#Hernia
#Surgery

VENTRAL HERNIA:

-Any protrusion through abdominal wall with the exception of hernia through the inguinofemoral region is defined as ventral hernia.
-Incisional hernia (80%) and primary defects in abdominal fascia which can cause umbilical hernia, epigastric hernia, paraumbilical hernia or Spigelian hernia are grouped under ventral hernia.

#Surgery

RECURRENT HERNIA (Inguinal)

-Incidence is 10%.
-If recurrence is within 3 years it is called as early.
-If it is after 3 years it is late.

#Surgery

What is the conjoint tendon?

-Aponeurotic attachments of the “conjoining” of the internal oblique and transversus abdominis to the pubic tubercle.

#Surgery

•What are the layers of the abdominal wall?

Skin
Subcutaneous fat
Scarpa’s fascia
External oblique Internal oblique Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum

•Note:
-All three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line.

#Surgery

•What is more dangerous: a small or large hernia defect?

-Small defect is more dangerous because a tight defect is more likely to strangulate if incarcerated.

•Incarcerated means:
Swollen or fixed within the hernia sac (incarcerated imprisoned); may cause intestinal obstruction (i.e., an irreducible hernia).

•Incisional hernia:
-Hernia through an incisional site; most common cause is a wound infection.

•Epigastric hernia:
-Hernia through the linea alba above the umbilicus.

•Cooper’s hernia:
-Hernia through the femoral canal and tracking into the scrotum or labia majus.

#Surgery

Cloquet's hernia is a hernial sac protruding underneath the fascia of the pectineus muscle, it is also highly liable to strangulate.

#Hernia
#Surgery

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.

#Hernia
#Surgery

Femoral hernia and the gender

The female to male ratio is 2:1, it is interesting that female patients are usually elderly, whereas male patients are usually between 35-40 years, so it useful to remember the quote (your grandmother and your father have femoral hernia)

#Hernia
#Surgery

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.

#Hernia
#Surgery

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.

#Hernia
#Surgery

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

#Hernia
#Surgery

The word VAN helps to remind you the order of structures within femoral triangle from medial to lateral they are

V= femoral Vein
A= femoral Artery
N= femoral Nerve

Dont forget the the most medial one is the femoral canal containing lymphatics and lymph nodes of Cloquet

#Hernia
#Surgery

#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.

#Hernia
#Surgery

Recurrence of Hernia after operation:

◼️Reports suggest that recurrence rate vary between 0.2% up to 15% depending on the technique used.

◼️Only by using meticulous technique principally concentrating on reinforcement of the posterior wall of inguinal canal with the shouldice technique or mesh hernioplasty can a recurrence rate of less than 2% be achieved.

◼️Only 50% of recurrences will become apparent within two years.

◼️In a few cases "false" recurrence occur, i.e another type of hernia occur - direct after indirect, femoral after inguinal. How ever to the patient it is recurrence!!

#Hernia
#Surgery

Direct inguinal hernia

◼️Figure above is a direct inguinal hernia descended into scrotum (unusual) with gangrene and sloughing of skin.
◼️They are always acquired and result from passage of the hernial sac through a point of weakness or a defect of transversalis fascia in posterior inguinal wall usually medial to the inferior epigastric vessels.
◼️Risk factors include male gender, smoking (thought to cause acquired collage defeciency), old age, straining or heavy lifting, and injury of the Ilioinguinal nerve (previous appendicectomy/more with Gridiron incision).
◼️Patients often have elongated buldings in the abdominal wall resulting from poor lower abdominal musculature (Malgaigne's buldgings).
◼️The sac is often smaller than the observed mass indicate because of thick coverings mainly made of extraperitoneal fat.
◼️The neck is wide thus strangulation is less often.
◼️If presented unilaterally, there is a fourfold higher risk of contralateral involvement in the future.

#Hernia
#Surgery

Examination sequence for hernia

◼️Examine the groin while the patient is standing up.
◼️Examine the inguinal and femoral canals and scrotum for any buldges.
◼️Identify the anatomical relationship between the buldge and pubic tubercle and the inguinal ligament to distinguish femoral from an inguinal hernia.
◼️Palpate the external inguinal ring and along the inguinal canal for any defects. Ask the patient to cough and feel for cough impulse.
◼️Instruct the patient to lie down and see whether the hernia reduce spontaneously or not.
◼️If so, press two fingers over the internal inguinal ring (midpoint between anterior superior iliac spine and pubic symphesis about 1.25cm above inguinal ligament) and ask the patient to cough if the hernia reappears it is DIRECT and if pressure prevent it from reappearing it is INDIRECT.
◼️Examine the opposite side for possibility of asymptomatic hernia (inguinal hernia is bilateral in 12% of cases).

#Hernia
#Surgery

#Inguinal_Triangle
◼️ Synonym=Hasselbach's triangle.
◼️Medial border is the lateral margin of rectus abdominis muscle.
◼️ Superolateral border is the inferior epigastric vessels.
◼️ Inferior border is the inguinal ligament.
◼️ It is a potential point of weakness, direct inguinal hernias occur medial to the inferior epigastric vessels in the inguinal triangle,, what is the exception to this rule?

#Hernia
#Surgery

Types of indirect inguinal hernia

◼️Bubonocele "Bubon is greek for groin", here the hernia is limited to the inguinal canal.

◼️Funicular "funiculus latin for small cord" Here the processus vaginalis is closed just above the epididymis, the contents of the sac can be felt seperately from the testis.

◼️ Complete (synonym = scrotal), it is rarely present at birth but commonly encountered thereafter during infancy, it can also occur in adolescents and adults, the testis appear to lie within the lower part of the hernia.

#Hernia
#Surgery