Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.

1. Dr.B.Selvaraj MS;MCh;FICS
Professor of Surgery
Melaka Manipal Medical college
Melaka Malaysia 75150
VENTRAL HERNIA

2. Ventral Hernia
 This term refers to hernias of the anterior abdominal
wall except groin hernias.
Ventral hernias
 Epigastric
 Umbilical & Paraumbilical
 Incisional
 Spigelian
 Lumbar

3. Epigastric Hernia
 It is the protrusion or herniation of extraperitoneal fat through a
defect in the linea alba anywhere between the xiphoid process
and the umbilicus, usually midway between these structures.
 The condition is always acquired, common in manual labourers
between the ages of 30 and 45yrs often precipitated by sudden
strain causing tearing of the interlacing fibres of the linea alba.
 Initially there is protrusion of extraperitoneal fat through the
same opening where the linea alba is pierced by a small blood
vessel. At this stage, there is no well-formed sac and it is called
fatty hernia of linea alba.

4. Epigastric Hernia
 In the next stage,
as the hernia grows
bigger and bigger,
it drags a pouch of
peritoneum after it
and becomes a true
epigastric hernia
which may contain
omentum or bowel

5. Epigastric Hernia-
Clinical Features
 There are three clinical types:
 Symptomless—At the initial stage it is symptomless and often
discovered by the patient himself as a swelling during washing his
body
 Painful swelling—Localized pain exactly at the site of hernia as
the fatty content of the hernia is pressed by the tight margins of
the gap in the linea alba to produce partial strangulation.
 Symptoms of peptic ulcer—As stated above. Pain may also be due
to associated peptic ulcer or gall stones

6. Epigastric Hernia-
Clinical Features
 O/E: There is a firm globular swelling, varying from a pea size to
2cm diameter, does not have cough impulse (usually) and can not
be reduced.
 The gap in the linea alba cannot be felt clearly. For this reason
epigastric hernia is difficult to distinguish from lipoma.
 Abdominal examination is normal.

7. Epigastric Hernia-
Treatment
 If small and
symptomless, the lump
can be overlooked.
 If there are symptoms,
operation is done.
Before operation patient
is advised for an upper
GI endoscopy to exclude
an underlying peptic
ulcer disease.

8. Umbilical Hernia-
In Children
 Umbilical hernia develops due to either absence of umbilical
fascia(Richet’s fascia) or incomplete closure of umbilical defect.
In children common cause is umbilical sepsis.
 This is common in male child (2:1), who is usually brought to the
doctor with the compliant of swelling in the umbilical region,
whenever the child cries.
 Most cases are symptomless but parents are anxious about the
swelling.
 Strangulation is rare.

9. Umbilical Hernia-
In Children

10. Umbilical Hernia-
In Children Treatment
 Conservative—Most of the
hernia close spontaneously
without any treatment within
two years of age. So the methods
are: masterly inactivity, reassure
parents and strapping over a
coin
 Operative—Herniorrhaphy is
indicated when the hernia is still
present after 2 years of age

11. Umbilical Hernia-
In Adults(Para umbilical)
 In adults, hernia does not protrude through the umbilical cicatrix.
It is a protrusion through the linea alba just above the umbilicus
(supraumbilical) or occasionally below the umbilicus
(infraumbilical). That’s why it is called paraumbilical hernia.
 Commonly occurs in middle-aged or elderly women (M:F = 1:5)
 Contributing factors are obesity, multiparous women, persistent
source of straining, e.g. chronic cough, constipation, bladder neck
obstruction

12. Umbilical Hernia-
In Adults(Para umbilical)
 The usual content is the greater omentum, often accompanied by
small intestine or a portion of the transverse colon.
 Owing to adhesions between the contents and the sac, the sac
becomes loculated in most cases and the hernia is usually
irreducible.
 There is a swelling in the umbilical region. Initially the swelling is
small but gradually it increases and attains a big size.

13. Umbilical Hernia-
In Adults(Para umbilical)
 Dragging pain may be present due to
adherent omentum.
 The swelling is firm in consistency as it
contains mostly omentum. Dull on
percussion. Cough impulse is present
when the contents are not adherent,
but absent when the hernia becomes
irreducible.
 After reducing the swelling, the defect
can be made out in the linea alba.

14. Umbilical Hernia-
In Adults(Para umbilical)
Complications
 Irreducibility
 Obstruction with colicky abdominal pain and vomiting, distension
follows soon. Untreated cases develop strangulation.
 As the sac enlarges, it sags down resulting in friction of skin and this
causes intertrigo (Dermatitis between the skin folds).

15. Umbilical Hernia-
In Adults(Para umbilical)
Treatment
 Mayo’s operation: After
weight reduction using
double breasting technique
 Mesh repair: For larger
defects – open or
Laparoscopic- Overlay or
IPOM

16. Incisional Hernia
Definition & Causes
 An incisional hernia is one where the peritoneal sac herniates
through an acquired scar in the abdominal wall usually caused by a
previous surgical operation or an accidental trauma.
 It is very common in females. Contents of such hernia are usually
bowel and/ or omentum.
 Precipitating factors: Many factors singly or in combination are
responsible
 Poor surgical technique: Non anatomic incision, Method of closure,
Inappropriate suture material, Suturing technique and Drainage
tube brought out through main wound.

17. Incisional Hernia
Causes
 Postoperative complications: Postoperative wound infection, cough,
and respiratory distress due to pneumonia or lung collapse.
 General factors: patients with severe anemia, hypoproteinemia,
diabetes, advanced malignant disease, jaundice, chronic renal
failure, steroid or immunosuppressive.
 Tissue failure: Late development of hernia after 5, 10 or more years
after operation is usually associated with tissue failure that is
abnormal collagen production and maintenance

18. Incisional Hernia
Clinical Features
 History: A previous operation or trauma is noticed. There may be
history of wound infection.
 Age: Incisional hernia may occur at any age but more commonly in
elderly females.
 Symptoms: Swelling and pain are the commonest symptoms.
Rarely features of intestinal obstruction may be present
 Signs: expansile impulse on coughing, reducibile, after reduction
can feel the defect through the scar

19. Incisional Hernia
Clinical Features
 Type1: It occurs through, the midline upper or lower abdominal
incision where the muscular defect is wide with smooth and regular
margins. Hence this hernia gets reduced spontaneously as soon as
the patient lies down. Risk of strangulation is almost negligible.
 Type 2: The hernia is situated in the lateral part of abdomen. Here
the risk of strangulation is more

20. Incisional Hernia
Clinical Features

21. Incisional Hernia
Treatment
 Conservative Approach: If the neck of the incisional hernia is wide
shows no signs of increase in size and patient has no symptoms, it
may be observed.
 Operative Treatment: The indications are:
 Symptomatic hernia which is showing signs of increasing in size
needs repair.
 Large hernia with a small defect. Such hernia has a high chance of
strangulation and needs to be repaired early. Subacute intestinal
obstruction, irreducibility and strangulation are definite indications
for repair of incisional hernia.

22. Incisional Hernia
Treatment
 Mesh repair: is
always better and
ideal with less
chances of
recurrence.
 Sublay or
Intraperitoneal
onlay mesh IPOM
 Anatomical repair
and Keel’s operation
not in vogue

23. Incisional Hernia
Treatment

24. Incisional Hernia
Treatment
 Large defect: Ramirez
component separation:
 20 cms mobilization is
achieved

25. Spigelian Hernia
 It is a type of inter parietal hernia
occurring at the level of arcuate line
through spigelian point
 Spigelian hernia can occur above (10%) or
below (90%) the umbilicus. Below the
umbilicus it occurs at the junction of linea
semilunaris and linea semicircularis

26. Spigelian Hernia
Clinical Features
 Presents as a soft, reducible mass lateral to the rectus muscle and
below the umbilicus, with impulse on coughing. Strangulation is
common
 Precipitating factors are obesity, chronic cough, old age, multiple
pregnancies.
 Common in females after 50 years of age.
 D/D: abdominal wall lipoma, abdominal wall hematoma & soft tissue
sarcoma

27. Spigelian Hernia
Treatment
Open or
Laparoscopic
Mesh Repair

28. Lumbar Hernia
Clinical Features
 It is herniation either through superior or
inferior lumbar triangle.
 Superior lumbar triangle
(Grynfelt’s/Lesgaft’s triangle) is bounded by
sacrospinalis, 12th rib and posterior border
of internal oblique
 Inferior lumbar triangle is bounded by
latissimus dorsi, external oblique and iliac
crest (triangle of Petit).
 Lumbar hernia is more common through
superior lumbar triangle.

29. Lumbar Hernia
Clinical Features
 It can be: Primary or
Secondary, which is due to
previous renal surgery, more
common.
 D/D: Lipoma, cold abscess and
lumbar phantom hernia
 Treatment : Repair using
fascial flaps or mesh.

30. “Surgical Educator” Channel
Link:
youtube.com/c/surgicaleducator