Hernias No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than Hernia in all its varieties. - PowerPoint PPT Presentation

1 / 43
About This Presentation
Title:

Hernias No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than Hernia in all its varieties.

Description:

By: Pr. Dr. Reda A. These hernias enlarge over time, leading to pain, bowel obstruction, incarceration, and strangulation. Large ventral hernias can result in loss of ... – PowerPoint PPT presentation

Number of Views:486
Avg rating:3.0/5.0

less

Transcript and Presenter's Notes

Title: Hernias No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than Hernia in all its varieties.


1
HerniasNo disease of the human body, belonging
to the province of the surgeon, requires in its
treatment a better combination of accurate
anatomical knowledge with surgical skill than
Hernia in all its varieties.


Sir Astley Paston Cooper
(1804)
  • By Pr. Dr. Reda A.

2
Introduction
  • It is an abnormal protrusion of an organ or
    tissue through a defect in its surrounding walls.
  • These sites most commonly include the inguinal,
    femoral, and umbilical areas, the linea alba, the
    lower portion of the semilunar line, and sites of
    prior incisions.

3
Abdominal Wall Hernias
  • Groin
  • Inguinal
  • Indirect
  • Direct
  • Combined
  • Femoral
  • Anterior
  • Umbilical
  • Ventral
  • Epigastric
  • lateral
  • hypogastric
  • Spigelian
  • Pelvic
  • Obturator
  • Sciatic
  • Perineal
  • Posterior
  • Lumbar

4
Incidence
  • Approximately 75 of all hernias occur in the
    inguinal region. Two thirds of these are
    indirect, and the remainder are direct inguinal
    hernias.
  • Men are 25 times more likely to have a groin
    hernia than women.
  • There is a female dominance in femoral and
    umbilical hernias of approximately 10 to 1 and 2
    to 1, respectively.
  • Strangulation, the most common serious
    complication of a hernia.

5
Etiology
  • Defect in the abdominal wall may be congenital
    (e.g. inguinal canal, femoral canal) or acquired
    (e.g. an incision).
  • Raised intra-abdominal pressure further weakens
    the defect allowing some of the intra-abdominal
    contents (e.g. omentum, small bowel loop) to
    migrate through the opening.
  • A chronic cough, straining on micturition
    or straining on defecation lifting a heavy
    weight are all increase the intra abdominal
    pressure
  • Smoking result of an acquired collagen deficiency
  • Stretching of the abdominal musculature because
    of an increase in contents, as in and intra
    abdominal mass like malignancy. Obesity, can be
    another factor.
  • Fat acts to separate muscle bundles and layers,
    weakens aponeuroses and favours the appearance of
    paraumbilical, direct inguinal and hiatus
    hernias.
  • congenital preformed sac

6
Composition of a hernia
  • As a rule, a hernia consists of three parts the
    sac, the coverings of the sac and the contents of
    the sac.
  • The sac
  • The sac is a diverticulum of peritoneum,
    consisting of mouth, neck, body and fundus. The
    neck is usually well defined but in some direct
    inguinal hernias and in many incisional hernias
    there is no actual neck. The diameter of the neck
    is important because strangulation of bowel is a
    likely complication when the neck is narrow, as
    in femoral and paraumbilical hernias.
  • The covering
  • Coverings are derived from the layers of the
    abdominal wall through which the sac passes.
  • Contents
  • These can be
  • omentum omentocele (synonymepiplocele)
  • intestine enterocele more commonly small
    bowel but may be large intestine or appendix
  • a portion of the circumference of the intestine
    Richters hernia
  • a portion of the bladder (or a diverticulum)
    may constitute part of or be the sole content of
    a direct inguinal, a sliding inguinal or a
    femoral hernia
  • ovary with or without the corresponding
    fallopian tube
  • a Meckels diverticulum a Littres hernia
  • fluid, as part of ascites or as a residuum
    thereof.

7
Pathology
  • An external hernia protrudes through all layers
    of the abdominal wall, whereas an internal hernia
    is a protrusion of intestine through a defect
    within the body cavity. An interparietal hernia
    occurs when the hernia sac is contained within a
    musculoaponeurotic layer of the abdominal wall
    eg Spigelian hernia .
  • Special forms
  • Sliding A sliding hernia occurs when a
    retroperitoneal organ comprises a portion of the
    wall of the hernia sac. The most common viscus
    involved is the colon or urinary bladder.
  • Most sliding hernias are a variant of
    indirect inguinal hernias, although femoral and
    direct sliding hernias can occur.
  • The primary danger associated with a
    sliding hernia is the failure to recognize the
    visceral component of the hernia sac and injury
    to the bowel or bladder.
  • Maydls (Strangulated loop above defect)

8
  • Common hernia
  • sliding hernia

9
Spigilian hernia
10
Complications
  • Entrapment of the contents in the sac leads to
    incarceration (unable to reduce contents) ,
    intestinal obstruction and possibly strangulation
    (blood supply to incarcerated contents is
    compromised).
  • Other complications include inflammation,
    hydrocele of hernial sac and rupture of hernial
    sac.

11
Classification
  • Hernia may be
  • Reducible hernias
  • The hernia either reduces itself when the patient
    lies down or can be reduced by the patient or the
    surgeon.
  • The intestine usually gurgles on reduction and
    the first portion is more difficult to reduce
    than the last.
  • Omentum, in contrast, is described as doughy and
    the last portion is more difficult to reduce than
    the first.
  • A reducible hernia imparts an expansile impulse
    on coughing.
  • Irreducible hernia
  • In this case the contents cannot be returned to
    the abdomen but there is no evidence of other
    complications. It is usually due to adhesions
    between the sac and its contents or overcrowding
    within the sac. Note that any degree of
    irreducibility predisposes to strangulation.
  • Obstructed hernia
  • This is an irreducible hernia containing
    intestine that is obstructed from without or
    within, but there is no interference to the blood
    supply to the bowel. The symptoms (colicky
    abdominal pain and tenderness over the hernia
    site) are less severe and the onset more gradual
    than in strangulated hernias, but more often than
    not the obstruction culminates in strangulation.
  • Usually there is no clear distinction clinically
    between obstruction and strangulation and the
    safe course is to assume that strangulation is
    imminent and treat accordingly.
  • Incarcerated hernia
  • The term incarceration is often used loosely as
    an alternative to obstruction or strangulation
    but is correctly employed only when it is
    considered that the lumen of that portion of the
    colon occupying a hernial sac is blocked with
    faeces.
  • Strangulated hernia
  • A hernia becomes strangulated when the blood
    supply of its contents is seriously impaired,
    rendering the contents ischaemic. Gangrene may
    occur as early as 56 hours after the onset of
    the first symptoms.

12
Strangulated herniaPathology
  • The intestine is obstructed and its blood supply
    impaired. Initially, only the venous return is
    impeded the wall of the intestine becomes
    congested and bright red with the transudation of
    serous fluid into the sac. As congestion
    increases the wall of the intestine becomes
    purple in colour. The intestinal pressure
    increases, distending the intestinal loop and
    impairing venous return further. As venous stasis
    increases, the arterial supply becomes more and
    more impaired. Blood is extravasated under the
    serosa and is effused into the lumen. The fluid
    in the sac becomes blood-stained and the shining
    serosa dull because of a fibrinous, sticky
    exudate. At this stage the walls of the intestine
    have lost their tone and become friable.
    Bacterial transudation occurs secondary to the
    lowered intestinal viability and the sac fluid
    becomes infected. Gangrene appears at the rings
    of constrictionwhich become deeply indented and
    grey in colour. The gangrene then develops in the
    anti-mesenteric border, the colour varying from
    black to green depending on the decomposition of
    blood in the subserosa. The mesentery involved by
    the strangulation also becomes gangrenous. If the
    strangulation is unrelieved, perforation of the
    wall of the intestine occurs, either at the
    convexity of the loop or at the seat of
    constriction. Peritonitis spreads from the sac to
    the peritoneal cavity.

13
Strangulated herniaClinical
features
  • Pain, at first situated over the hernia, is
    followed by generalised abdominal pain, colicky
    in character and often located mainly at the
    umbilicus. Nausea and subsequently vomiting
    ensue.
  • The patient may complain of an increase in hernia
    size.
  • On examination the hernia is tense, extremely
    tender and irreducible, and there is no expansile
    cough impulse.

14
Clinical features hernia
  • Painless bulge which increase with straining and
    disappear on laying down patients may complain
    of a full or dragging sensation . Hernias are
    usually not painful unless complicated or huge .
  • Predisposing factors and complications should be
    included during history taking .
  • Bulge elicited with the Valsalva maneuver,
    coughing or straining helps demonstrate small
    hernias.
  • On examination you could find a mass in a sit of
    hernial orifice which is reducable , and gives
    impuls on cough.
  • Femoral hernias are below and lateral to the
    pubic tubercle,50 present as a surgical
    emergency due to obstructed contents.
  • Inguinal hernias start off above and medial to
    the pubic tubercle but may descend broadly when
    larger.
  • (a) Indirect inguinal hernias can be controlled
    by digital pressure over the internal inguinal
    ring, and are common in younger.
  • (b) Direct inguinal hernias are poorly controlled
    by digital pressure and are commoner in older men
    .
  • Finally, a fingertip is placed into the
    inguinal canal by invaginating the scrotum to
    detect a small hernia. A bulge moving lateral to
    medial in the inguinal canal suggests an indirect
    hernia. If a bulge progresses from deep to
    superficial through the inguinal floor, a direct
    hernia is suspected.

15
Clinical features
  • Incisional hernias bulge through previous scar ,
    and are accentuated by tensing the recti. Large
    incisional hernias may contain much of the small
    bowel and may by irreducible/ dificult in repair
    due to the loss of the right of abode in the
    abdomen of the contents.
  • True umbilical hernias are present from birth and
    are symmetrical defects in the umbilicus due to
    failure to close. Or can be seen in ascetics
  • Para-umbilical hernias develop due to an
    acquired defect in the periumbilical fascia below
    or above the umbilicus.
  • The evaluation of other abdominal wall hernias
    also requires diligent physical examination. As
    with the inguinal region, the anterior abdominal
    wall should be evaluated
  • Assess the hernia for predisposing factors
    ,severity of symptoms, risk of complications
    (type, size of neck), ease of repair (size,
    location), likelihood of success (size, loss of
    right of abode).
  • Assess the patient for fitness for surgery,
    impact of hernia on lifestyle (job, hobbies).

16
inguinal hernia
  • Types of inguinal hernia
  • Inguinal hernias are classified as either direct
    or indirect. The sac of an indirect inguinal
    hernia passes from the internal inguinal ring
    obliquely toward the external inguinal ring and
    ultimately into the scrotum. In contrast, the
    sac of a direct inguinal hernia protrudes outward
    and forward and is medial to the internal
    inguinal ring and inferior epigastric vessels.
    Combined inguinal hernia are bouth direct and
    indirect

17
Anatomy of the inguinal canal
  • The inguinal canal is approximately 4 cm in
    length and is located 2 to 4 cm cephalad to the
    inguinal ligament. In infants, the superficial
    and deep inguinal rings are almost
  • superimposed and the obliquity of the canal is
    slight
  • The canal extends between the internal (deep)
    inguinal and the external (superficial) inguinal
    rings.
  • The superficial inguinal ring is a triangular
    aperture in the aponeurosis of the external
    oblique muscle and lies 1.25 cm above the pubic
    tubercle.
  • The deep inguinal ring is a U-shaped condensation
    of the transversalis fascia and it lies 1.25 cm
    above the inguinal (Pouparts) ligament, midway
    between the symphysis pubis and the anterior
    superior iliac spine.
  • The anterior boundary comprises mainly the
    external oblique aponeurosis with the conjoined
    muscle laterally.
  • The posterior boundary is formed by the fascia
    transversalis and the conjoined tendon (internal
    oblique and transversus abdominus medially).
  • The inferior epigastric vessels lie posteriorly
    and medially to the deep inguinal ring.
  • The superior boundary is formed by the conjoined
    muscles (internal oblique and transversus)
  • and the inferior boundary is the inguinal
    ligament.

18
(No Transcript)
19
Content of the inguinal canal
  • The inguinal canal contains the spermatic cord or
    the round ligament of the uterus.
  • The spermatic cord is composed of cremasteric
    muscle fibers, external and internal spermatic
    fascia the testicular artery and accompanying
    veins, the genital branch of the genitofemoral
    nerve, the vas deferens, the cremasteric vessels,
    the lymphatics, and the processus vaginalis.
  • The iliohypogastric and ilioinguinal nerves and
    the genital branch of the genitofemoral nerve are
    the important nerves in the groin area
  • The iliohypogastric and ilioinguinal nerves
    provide sensation to the skin of the groin, the
    base of the penis, and the ipsilateral upper
    medial thigh.
  • The genital nerve innervates the cremaster muscle
    and the skin on the lateral side of the scrotum
    and labia

20
The Hesselbach triangle
  • The inferior epigastric vessels serve as its
    superolateral border, the rectus sheath as medial
    border, and the inguinal ligament as the inferior
    border. Direct hernias occur within the
    Hesselbach triangle, whereas indirect inguinal
    hernias arise lateral to the triangle

21
Direct and indirect inguinal hernia
22
Femoral Canal
  • The boundaries of the femoral ring are
  • anteriorly by the inguinal ligament
  • posteriorly by Astley Coopers (iliopectineal)
    ligament, the pubic bone and the fascia over the
    pectineus muscle
  • medially by the concave knife-like edge of
    Gimbernats (lacunar) ligament, which is also
    prolonged along the iliopectineal line, as Astley
    Coopers ligament
  • laterally by a thin septum separating it from
    the femoral vein.
  • A femoral hernia occurs through this space and is
    medial to the femoral vessels

23
Inguinal hernia
24
Differential diagnosis of inguinal hernia
  • In the male
  • vaginal hydrocele
  • encysted hydrocele of the cord
  • spermatocele
  • femoral hernia
  • incompletely descended testis in the inguinal
    canal an
  • inguinal hernia is often associated with this
    condition
  • lipoma of the cord this is often a difficult
    but unimportant diagnosis and it is usually not
    settled until the parts are displayedby
    operation.
  • In females
  • hydrocele of the canal of Nuck this is the
    most common differential
  • diagnostic problem
  • femoral hernia.

25
Treatment of inguinal hernia
  • Most surgeons recommend operation on discovery of
    an inguinal hernia because the natural history of
    a groin hernia is that of progressive enlargement
    and weakening, with the potential for
    incarceration and strangulation.
  • In adults, local, epidural or spinal, as well as
    general anaesthesia, can be used
  • Principles of surgery
  • Herniotomy The basic operation is inguinal
    herniotomy, which entails dissecting out and
    opening the hernial sac, reducing any contents
    and then transfixing the neck of the sac and
    removing the remainder. It is employed either by
    itself or as the first step in a repair procedure
    (herniorrhaphy).
  • Herniorrhaphy consists of (1) excisionof the
    hernial sac plus (2) repair of the stretched
    internal
  • inguinal ring and the transversalis
    fascia and (3) further reinforcement of the
    posterior wall of the inguinal canal. (2) and
    (3) must be achieved without tension resulting in
    the wound and various techniques exist to achieve
    this, e.g. Shouldice operation.
  • Hernioplasty repair the defect with prosthetic
    mish
  • The Lichtenstein tension-free hernia repair.
  • This procedure is performed by careful
    dissection of the inguinal canal.
  • High ligation of an indirect hernia sac is
    performed
  • An 8 11-cm sheet of Marlex mesh is fashioned to
    fit the inguinal canal.
  • And a new internal ring is made by mesh.
  • It can be done by Laparoscopy .

26
(No Transcript)
27
Nyhus Classification of Groin Hernia
  • Type I Indirect inguinal herniainternal
    inguinal ring normal(e.g., pediatric hernia)
  • Type II Indirect inguinal herniainternal
    inguinal ring dilated but posterior inguinal wall
    intact inferior deep epigastric vessels not
    displaced
  • Type III Posterior wall defect
  • A. Direct inguinal hernia
  • B. Indirect inguinal
    herniainternal inguinal ring dilated,
    medially encroaching on or destroying the
    transversalis fascia of Hesselbachs triangle
    (e.g., massive scrotal, sliding, or pantaloon
    hernia)
  • C. Femoral hernia
  • Type IV Recurrent hernia
  • A. Direct
  • B. Indirect
  • C. Femoral
  • D. Combined

28
femoral hernia
  • It is more common in female
  • Usually presented by strangulated hernia
    Presented by SS of intestinal obstruction
    together with painful swelling in the femoral
    triangle ( below and lateral to pubic tubercle )
    may go up if large
  • DD An inguinal hernia. The neck of the sac
    lies above and medial to the medial end of the
    inguinal ligament at its attachment to the pubic
    tubercle. The neck of the sac of a femoral hernia
    lies below and lateral to this
  • A saphena varix. The swelling
    disappears completely when the patient lies flat
    whereas a femoral hernia sac is usually still
    palpable. In both, there is an impulse on
    coughing. A saphena varix will, however, impart a
    fluid thrill to the examining fingers when the
    patient coughs or when the saphenous vein below
    the varix is tapped with the fingers of the other
    hand.
  • An enlarged femoral lymph node. There
    may be other enlarged lymph nodes to aid the
    diagnosis. If Cloquets lymph node alone is
    affected it may be impossible to distinguish from
    a femoral hernia sac unless there are other
    clues, such as an infected wound or abrasion on
    the corresponding limb or on the perineum.
  • Lipoma.
  • A femoral aneurysm.
  • A psoas abscess. There is often a
    fluctuating swelling an iliac abscess which
    communicates with the swelling in question. If
    suspected, an examination of the spine and a
    radiograph will confirm the diagnosis
  • A distended psoas bursa. The swelling
    diminishes when the hip is flexed and
    osteoarthritis of the hip is present.
  • Rupture of the adductor longus with
    haematoma formation. Suspected on clinical
    history
  • A femoral hernia can be repaired using the
    standard Cooper ligament repair, a preperitoneal
    approach, or a laparoscopic approach

29
UMBILICAL HERNIA
  • Exomphalos ( minor lt5cm major ) is a
    congenital umbilical hernia in neonate due to
    failiar of mid gut ton return to the abdomen .
    The bowel is covered by amniotic membrane and
    whartons jelly . It is treated by urgent
    surgery
  • Umbilical hernias in infants ( infantile
    umbilical hernia) are congenital and are quite
    common. They close spontaneously in the vast
    majority of cases by the age of 2 years. Those
    that persist after the age of 5 years are
    frequently repaired surgically, although
    complications related to these hernias in
    children are unusual.
  • Umbilical hernias in adults are largely acquired.
    These hernias occur more frequently in women and
    in patients with conditions that result in
    increased intra-abdominal pressure, such as
    pregnancy, obesity, ascites, or abdominal
    distention. Strangulation and rupture of the
    hernia can occur in chronic ascitic conditions.
    Adults who have symptoms, a large hernia,
    incarceration, thinning of the overlying skin, or
    uncontrollable ascites should have hernia repair.
  • Paraumbilical hernia occur due to defect in
    linia alba just above ( commoner) or below the
    umbilicus . It is usually partially irreducible
    because of the formation of omental adhesions
    within the sacand the neck of the sac is often
    remarkably narrow compared with the size of the
    sac and the volume of its contents. Women are
    affected five times more frequently than men. The
    patient is usually overweight and between the
    ages of 35 and 50. Repeated pregnancy are
    important aetiological factors. Symptomatically,
    a large umbilical hernia causes a dragging pain
    because of its weight. Gastrointestinal symptoms
    are common and are probably due to traction on
    the stomach or transverse colon. Often there are
    transient attacks of intestinal colic because of
    partial intestinal obstruction.
  • In long-standing cases, intertrigo of the
    adjacent surfaces of skin and trophic ulcers of
    the fundus are troublesome complications.
  • Classically, repair was done using the
    vest-over-pants repair proposed by Mayo.
  • Larger defects (greater than 3 to 4 cm)
    should be closed using prosthetic mesh .
  • Also can be repaired by a laparoscopic
    approach with intra-abdominal mesh placement

30
UMBILICAL HERNIA
31
EPIGASTRIC HERNIAS
  • Epigastric hernias are two to three times more
    common in men. These hernias are located between
    the xiphoid process and umbilicus and are usually
    within 5 to 6 cm above the umbilicus.
  • The defects are small and often produce pain out
    of proportion to their size owing to
    incarceration of preperitoneal fat.
  • They are multiple in up to 20 of patients.
    Repair is often accomplished by simple closure of
    the fascial defect .

32
INCISIONAL AND VENTRAL HERNIAS
  • Incisional hernias have been reported to occur in
    up to 10 of laparotomies.
  • Incisional hernias occur as a result of excessive
    tension and inadequate healing of a previous
    incision, which is often associated with surgical
    site infections.
  • Obesity, advanced age, malnutrition, ascites,
    pregnancy, and conditions that increase
    intraabdominal pressure are predisposing factors
    for the development of an incisional hernia.
  • Chronic pulmonary disease and diabetes mellitus
    have also been recognized as risk factors for the
    development of incisional hernia.
  • Medications such as corticosteroids and
    chemotherapeutic agents and can contribute to
    poor wound healing and increase the risk of
    developing an incisional hernia.

33
(No Transcript)
34
INCISIONAL AND VENTRAL HERNIAS
  • These hernias enlarge over time, leading to pain,
    bowel obstruction, incarceration, and
    strangulation.
  • Large ventral hernias can result in loss of
    abdominal domain, which occurs when the abdominal
    contents no longer reside in the abdominal
    cavity.
  • Return of displaced viscera to the abdominal
    cavity during repair may lead to increased
    abdominal pressure, abdominal compartment
    syndrome, and acute respiratory failure.
  • Primary repair of incisional hernias can be done
    when the defect is small (lt4 cm) and there is
    viable surrounding tissue. Larger defects (gt4 cm
    in diameter) have a high recurrence rate if
    closed primarily and should be repaired with a
    prosthesis. Recurrence rates vary between 10 and
    50 and are generally lower with prosthetic mesh
    repairs. Prosthetic material may be placed as an
    on-lay patch to buttress a tissue repair,
    interposed between the fascial defect, or
    sandwiched ( in-lay) between tissue planes.
  • The use of laparoscopic ventral hernia repair has
    been increasing, particularly for large defects.

35
Management of Strangulated Hernias
  • Causes
  • Pathology
  • Clinical picture
  • Preoperative treatment of strangulated hernias
  • Resuscitate with adequate fluids and
    electrolyte
  • Empty stomach with nasogastric tube
  • Give antibiotics to contain infection
  • Catheterise to monitor haemodynamic state
  • Repair of a suspected strangulated hernia is an
    emergency. The hernia sac opened first and the
    contents can be directly visualized and their
    viability assessed. The constricting ring is
    identified and can be incised to free the
    entrapped viscus with minimal danger to the
    surrounding organs, blood vessels, and nerves.
    If it is necessary to resect strangulated
    intestine, the peritoneum can be opened and
    resection done without the need for a second
    incision.

36
Complication of hernia repair
  • Wound infection Vs Prosthesis infection
  • Hematoma
  • Pulmonary embolism
  • Ischemic orchitis
  • Testicular atrophy
  • Acute urinary retention.
  • Chronic pain.
  • Hernia recurrence. The recurrence rate after
    surgery should be less than 2
  • Nerve Injuries The nerves most commonly affected
    during open hernia repair are the ilioinguinal,
    genital branch of the genitofemoral, and
    iliohypogastric .Transient neuralgias can occur
    and are usually self-limited and resolve within a
    few weeks after operation. Persistent neuralgias
    usually result in pain and hyperesthesia in the
    area of distribution. Symptoms are often
    reproduced by palpation over the point of
    entrapment. Transection of a sensory nerve
    usually results in an area of numbness
    corresponding to the distribution of the involved
    nerve

37
Burst abdomen
  • Also known as abdominal wound dehiscence, wound
    failure, wound disruption, evisceration, and
    eventration.
  • Describes partial or complete postoperative
    separation of an abdominal wound closure with
    protrusion or evisceration of the abdominal
    contents.
  • Wound dehiscence and incisional hernia are part
    of the same wound failure process
  • Dehiscence of the wound occurs before cutaneous
    healing, while incisional hernias lie under a
    well-healed skin incision.
  • Accompanied by high morbidity and mortality.

38
CLINICAL MANIFESTATION
  • Dehiscence usually declares itself 7-14 days
    post-operative .
  • May manifest following straining or removal of
    the sutures.
  • Patient often notes a ripping sensation or a
    feeling that something has given way.
  • Impending dehiscence of the abdominal wall is
    often preceded by the appearance of a salmon-pink
    serous discharge from the wound.

39
RISK FACTORS FOR ABDOMINALWOUND DEHISCENCE
  • These may conveniently be divided into
    preoperative factors, operative factors, and
    post-operative factors.

40
Pre-Operative Factors
  • Male Sex Among patients with wound dehiscence
    men outnumber women by at least 2 to 1
  • Age The incidence in the aged is higher
  • lt45 y.o. dehiscence occurs in 1.3
  • gt45 y.o. dehiscence occurs in 5.4
  • Emergency Operation Has been shown to be a risk
    factor for dehiscence in some studies. May be
    related more to haemodynamic instability than too
    the unscheduled procedure.
  • Diabetesdiabetes failed at a rate of 25,
    usually secondary to wound sepsis. The
    introduction of insulin improved these results.
  • Renal failure.
  • Jaundice.
  • Anaemia.
  • Malnutritution Protein deficencies Vitamin C
  • Corticosteriods

41
Operative Factors
  • Incision type
  • Closure Mass versus Layered Closure
  • Interrupted versus Continuous Sutures
  • Suture Materials
  • Size of Tissue Bite stitch interval and the
    tissue bite are 1cm
  • Suture Length-to-Wound Length Ratio 41

42
Post-Operative Factors
  • Elevation of Intra-Abdominal Pressure This may be
    due to coughing, vomitting , ileus, urinary
    retention
  • Wound Infection
  • Radiation TherapyBoth in the past and
    perioperatively
  • Chimotherapy .

43
TREATMENT
  • For most patients immediate re-operation is
    indicated
  • Pre-operative preparation include
  • To cover the exposed bowel with sterile wet gauze
  • broad spectrum antibiotics should be given.
  • Morphia
  • Intravenous fluid therapy
  • Nell Per Oss
Write a Comment
User Comments (0)
About PowerShow.com