Transcript The liver

Abdominal wall
Paraumbilical hernia of adults :
(syn. supra- or inftaumbilical hernia). In adults the hernia does
not occur through the umbilical scar. It is a protrusion through
the linea alba just above or sometimes just below the
umbilicus. As it enlarges, it becomes rounded or oval in shape
with a tendency to sag downwards. Paraumbilical hernias can
become very large. The neck of the sac is often remarkably
narrow as compared with the size of the sac and the volume of
its contents, which consist of greater omentum often
accompanied by small intestine and, alternatively or in addition,
a portion of the transverse colon. In long-standing cases the
sac sometimes becomes loculated due to adherence of
omentum to its fundus.
Clinical features :
Women are affected five times more frequently than men.
The patient is usually between the ages of 35 and 50.
Increasing obesity, with flabbiness of the abdominal muscles,
and repeated pregnancy’ are important antecedents. These
hernias soon become irreducible because of omental adhesions
within the sac. A large umbilical hernia causes a local dragging
pain by 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 due to
subacute intestinal obstruction. In long-standing cases,
intertrigo of the adjacent surfaces of the skin is a troublesome
complication.
Treatment :
Untreated, the hernia increases in size, and more and more of
its contents become irreducible. Eventually, strangulation may
occur. Therefore without undue delay operation should be
advised in nearly all cases. When small, the defect can be
closed by a simple repair using interrupted unabsorbable
sutures: for larger hernias, a Mayo technique is advisable.
Or mesh repair can be done
Epigastric hernia
A midline epigastric hernia (syn. fatty hernia of the linea alba)
occurs through the linea alba anywhere between the xiphoid
process and the umbilicus, usually midway between these
structures. Such a hernia commences as a protrusion of
extraperitoneal fat through the linea alba, where it is pierced by
a small blood vessel.
More than one hernia may be present and recurrence can
happen due to failure of identification of other defect at time of
original repair.
A swelling the size of a pea consists of a protrusion of
extraperitoneal fat only (fatty hernia of the linea alba). If the
protrusion enlarges, it drags a pouch of peritoneurn after it,
and so becomes a true epigastric hernia. The mouth of the
hernia is rarely large enough to permit a portion of hollow
viscus to enter it; consequently, either the sac is empty or it
contains a small portion of greater omentum.
Clinical features.
• Symptomless. A small fatty hernia of the linea alba can be felt
better than it can be seen, and may be symptomless, being
discovered only in the course of routine abdominal palpation.
• Painfnl. Sometimes such a hernia gives rise to attacks of local
pain (worse on physical exertion) and also tenderness to touch
and tight clothing; possibly because the fatty contents become
nipped sufficiently to produce partial strangulation.
•Referred pain (dyspeptic cases). It is not uncommon to find that
the patient, who may not have noticed the hernia, complains
pain relating to digestion. Which may simulate features of of
peptic ulcers.
Treatment. If the hernia is giving rise to symptoms, operation
should be undertaken. It is essential to mark the hernia before
the anaesthesia is given as it may be impossible to locate the
defect if the fatty protrusion retracts into the abdomen.
ABDOMINAL WALL
BURST ABDOMEN AND INCISIONAL
HERNIA
Factors relating to the incidence of burst abdomen and
incisionsal hernia.
Technique of wound closure:
• choice ~ suture materials — catgut leads to a higher
incidence of bursts than the use of non-absorbable
monofilament polypropylene. Polyamide.
• method ~ closure — interrupted suturing has a low incidence.
Thru’ and Thru’ suturing is good for the obstructed case. A onelayer closure has low incidence but it is higher than that
following a two-layered closure. Interrupted ‘far and near’
sutures are a recommended technique for single layer mass
closures. When continuous suturing of layers (one or two) is
performed a particular fault is the use of a short length of
material, pulled tightly, for in an anaesthetised relaxed patient
the incision is shortened thereby, and made taut so that the
material will act as if it were a cheese wire cutter when the
patient is conscious and coughing.
• drainage directly through a wound leads to a higher incidence
of ‘bursts’ than employing drainage through a separate (stab)
incision.
Factors relating to incisions.
Midline and vertical incisions have a tendency to burst which is
higher than those which are transverse.
Reason for operation
Infected case: deep wound infection has a notorious reputation
for causing burst abdomen and/or late incisional hernia.
Operations on the pancreas, with leakage of enzymes, and on
obstructed cases are other reasons for disruption.
Coughing,; vomiting; distension. At the completion of an
operation any violent coughing set off by the removal of an
endotracheal tube and suction of the laryngopharynx strains
the sutures. Likewise cough, vomiting and distension (e.g.
due to ileus) in the early postoperative period. Overvigorous
postoperative ventilation in sedated patients can lead to
wound disruption.
Causes of burst abdomen
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Poor closure technique
Deep wound infection
Coughing or vomiting
Poor metabolic state of patient
General condition of the patient.
Obesity, jaundice, malignant disease, hypoproteinaemia. anaemia
are all factors conducive to disruption of a laparotomy wound
Abdominal wounds in pregnancy are notorious for a high risk of
disruption.
Burst abdomen and incisional hernia
In 1–2% of cases, mostly between the sixth and eighth day after
operation, an abdominal wound bursts open and viscera are
extruded. The disruption of the wound tends to occur a few days
Before hand when the sutures apposing the deep layers
(peritoneum,posterior rectus sheath) tear through or even
become untied. An incisional hernia usually starts as a
symptomless partial disruption of the deeper layers during the
immediate or early postoperative period, the event passing
unnoticed if the skin wound remains intact after the skin
sutures have been removed.
Burst abdomen (syn. abdominal dehiscence)
Clinical features. A serosanguineous (pink) discharge from the
wound is a forerunner of disruption in fully 50 per cent of
cases. It is the most pathognomonic sign of impending wound
disruption, and it signifies that intraperitoneal contents are lying
extraperitoneally. Patients often volunteer the information that
they ‘felt something give way’. If skin sutures have been
removed, omentum or coils of intestine may be forced through
the wound and will be found lying on the skin. Pain and shock
are often absent. It is important to note that there may be
symptoms and signs of intestinal obstruction.
Treatment. An emergency operation is required to replace the
bowel, relieve any obstruction, and to resuture the wound.
While awaiting operation, reassure the patient and cover the
wound with a sterile towel. The stomach is emptied by a gastric
tube and intravenous fluid therapy commenced.
Incisional hernia (syn. ventral hernia; postoperative
hernia)
Aetiology. Incisional hernia occurs most often in obese individuals,
and a persistent postoperative cough and postoperative
abdominal distension are its precursors. There is a high
incidence of incisional hernia following operations for peritonitis
because, as a rule, the wound becomes infected. The placing of
a drainage tube through a separate stab incision, as opposed to
bringing such a tube through the laparotomy wound, reduces
the frequency.
An incisional hernia usually starts as a symptomless partial
disruption of the deeper layers of a laparotomy wound during
the immediate or very early postoperative period. Often the
event passes unnoticed if the skin wound remains intact after
the stitches have been removed. A serosanguineous discharge
is often the signal of dehiscence, and resuture of the deeper
disrupted layers of the incision obviates the more difficult repair
of an established and much larger hernia later on
Clinical features.
There are great variations in the degree of herniation. The hernia
may occur through a small portion of the scar, often the lower
end. More frequently there is a diffuse bulging of the whole
length of the incision. A postoperative hernia, especially one
through a lower abdominal scar, usually increases steadily in
size, and more and more of its contents become irreducible.
Sometimes the skin overlying it is so thin and atrophic that
normal peristalsis can be seen in the underlying coils of
intestine. Attacks of subacute intestinal obstruction are
common, and strangulation is liable to occur at the neck of a
small sac or in a loculus of a large one, Nevertheless, most
cases of incisional hernia are asymptomatic and broad-necked
and do not need treatment.
Treatment.
Palliative. An abdominal belt is sometimes satisfactory, especially
in cases of a hernia through an upper abdominal incision.
Operation. Many procedures are advocated, which is testimony to
the facts that the repairs may be difficult to accomplish and no
single procedure is dearly superior to the rest.
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