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nterior bdominal Wall Layer of anterior abdominal wall
A- Lateral:
1- Skin.2- Subcutaneous tissue.
3- External oblique muscle.
4- Internal oblique muscle.
5- Transversus abdominis muscle.
6- Fascia transversalis.
7- Peritoneum.
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1- Skin
A- Lateral
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2- Subcutaneous tissue
A- Lateral
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FasciaSuperficial:
Campers fascia
Continuous with fascia over thorax and thigh.
Fatty layer.
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FasciaDeep Superficial:
Scarpas fascia
Membranous layer.
Continues into perineum as:
Superficial perineal fascia = Colles fascia.
Deep:Thin layer covering abdominal muscles.
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3- External Oblique m.
A- Lateral
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4- Internal Oblique m.
A- Lateral
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5- Transversus abdominis m.
A- Lateral
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6- Fascia Transversalis m
A- Lateral
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7- Peritoneum
A- Lateral
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nterior bdominal Wall Layer of anterior abdominal wall
B- Medial:
1- Skin.
2- Superficial fascia.3- Anterior wall of rectus sheath.
4- Rectus muscle.
5- Posterior wall of rectus sheath.
6- Peritoneum.
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1- Skin
B- Medial
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2- Subcutaneous tissue
B- Medial
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3- Ant. Wall of Rectus
sheath
B- Medial
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4- Rectus Muscle
B- Medial
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B- Medial
5- Post. Wall of Rectussheath
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B- Medial
6- Peritoneum
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External Oblique Muscle
OriginFleshy digitations
from the lower 8 ribs
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External Oblique Muscle
The muscle is inserted by fleshy fibers as well asaponeurosis, as follows:
A- Fleshy fibers:
Outer lip of the iliac crest
B- Aponeurosis:
1. Medial part linea alba from xiphoid process to
symphysis pubis
2. Lateral part folded upwards & backwards upon itself
to form the inguinal ligament (ASIS pubic tubercle)
InsertionXiphoid
Process
Symphysis
Pubis
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External Oblique Muscle
Direction of fibersDownward
Forwards
Medially
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External Oblique Muscle
Nerve SupplyIntercostal nerves (T7 -T11) &
Subcostal nerve (T12)
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External Oblique MuscleA triangular shaped defect in the external oblique
aponeurosis lies immediately above and medial to thepubic tubercle, known as superficial inguinal ring
Between the anterosuperior iliac spine and the pubictubercle, the lower border of the aponeurosis is foldedbackward on itself, forming the inguinal ligament
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Internal Oblique Muscle
Origin
Insertion
1. Anterior 2/3 of the intermediate line of the iliac crest2. The lateral 2/3 of the inguinal ligament
3. Lumbar fascia
1. Lower 6 costal cartilages
2. Xiphoid process
3. Linea Alba
4. Pubic crest
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Internal Oblique Muscle
Direction of fibersUpwards
Forwards
Medially
Nerve SupplyT7-T12
Iliohypogastric n.
Ilioinguinal n.
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Transversus Abdominis Muscle
Origin
1- Lower 6 intercostal cartilages
2- Lumbar Fascia
3- Ant. 2/3 of inner lip of iliac crest
4- Lat. 1/3 of inguinal ligament
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Transversus Abdominis Muscle
Insertion
1- Xiphoid Process
2- Pubic Crest
3- Linea Alba
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Direction of fibersTransversus Abdominis Muscle
Horizontally
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Nerve SupplyTransversus Abdominis Muscle
T7-T12
Iliohypogastric n.
Ilioinguinal n.
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The part of the fascia which lines the innersurface of the transverse abdominus muscle
is called the fascia tranversalis.
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The main arteries of the abdominal wall andpelvis lie deep to the fascia tranversalis,while
the main nerves are superficial to it
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Rectus Abdominis
Muscle
Origin
From the pubic crest
Insertion
7th, 6th, 5th costal cartilages
Xiphoid process
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Rectus Abdominis
Muscle
Surgical Importance
The muscle is divided into segments
by tendinous intersections, Which
indicate that the muscle arises from anumber of myotomes, fused together
1- Segmental nerve supply.
2- Hematoma of rectus m. is localized
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Pyramidalis Muscle
It is a landmark of linea
alba intraoperative
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Rectus Sheath Is a long fibrous sheath
Encloses the rectus abdominis and pyramidalis
muscle (if present)
Contains the anterior rami of lower six thoracicnerves and the superior and inferior epigastric
vessels and lymph vessels
Formed mainly by aponeurosis of three lateralabdominal muscles
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Medially
Laterally
Rectus Sheath
Linea Alba
Linea Semilunaris
Arcuate Line
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Rectus Sheath
Falciform Ligament
External Oblique
Internal Oblique
Transversus Abdominis
Ant. Layer of Rectus Sheath
Post. Layer of Rectus Sheath
Rectus Abdominis
Above Arcuate Line
SKIN
PeritoneumTransverslais Fascia
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Rectus Sheath
External Oblique
Internal Oblique
Transversus Abdominis
Ant. Layer of Rectus Sheath
Rectus Abdominis
Below Arcuate Line
Urachus in Median Umbilical Fold
Medial Umbilical Ligament
Transverslais Fascia
SKIN
Peritoneum
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It is formed by the fusion of the aponeurosisof the abdominal muscles and it separates
the left and right rectus abdominus muscles.
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Applied anatomy In multiparae the upper part of the linea alba becomes
streched out and weak,so that fingers can beinsinuated between the two recti.the condition
known as Divarication of recti.
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It is a curved tendinous line placed one oneither side of the rectus abdominus,extends
from the 9thrib to the pubic tubercle.
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Actions of Anterior Abdominal Wall Muscles
They assist in raising the intra abdominal pressure (so,they help in vomiting, cough, delivery, etc.)
Keep the abdominal viscera in position. Rectus abdominis flexes the trunk, while the 2 oblique
muscles bend the trunk laterally.
Act as accessory expiratory muscles.
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Superior epigastric a.
Subcostal a.
Inferior epigastric a.
Deep circumflex iliac a.
- I -
Internal Mammary a.
- III -External Iliac a.
- II -
Descending Aorta
10th, 11thintercostal a.
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Lymphatic DrainageAbove the umbilicus:
Drain into the axillary and sternal nodes.
Below the umbilicus:
Drain into the superficial inguinal nodes.
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Venous Drainage Superficial veins are paired with arteries.
Above the umbilicus:
Drain into the azygos venous system. Below the umbilicus:
Drain into the femoral system (via greatsaphenous).
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Caput Medusae
The superficial veins around the umbilicus and theparaumbilical veins connecting them to the portal
vein may become grossly distended in case of
portal vein obstruction
The distended subcutaneous veins radiate outfrom the umbilicus, producing in severe cases the
clinical picture called Caput Medusae
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INGUINAL CANAL
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Inguinal canals
why have them?Allow contents of the scrotum to communicate with
intra-abdominal contents
Prevent mobile intra-abdominal contents (e.g.intestine) from entering the scrotum and possiblybecoming damaged, while at the same time permittingblood vessels, nerves, lymphatics, vas deferens etc. tosupply the scrotal contents
58Dr C Slater, Department of Human Biology, University of Cape Town
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A Box?
59
Floor
Imagine the right side inguinal canal viewed from the front as a
box with anterior &posterior walls, a roof & floor. The arrow
indicates that structures can run through it from lateral to medial
e.g. in males it transmits the spermatic cord, and in females,
the round ligament of the uterus.
Medial
Lateral
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Inguinal canal
60
Floor
Medial
Here are the posterior wall, which has the DEEP inguinal
ring situated laterally, and the floor. (Roof and anterior wall
removed).
Deep inguinal ring
Lateral
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Inguinal canal
61
Floor
Medial
Here are the anterior wall (which has the SUPERFICIAL
inguinal ring situated medially), and the roof.
Superficial inguinal ring
Lateral
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Inguinal canal
62
FloorSpermatic cord
exits through
the superficial
inguinal ring
Medial
Spermatic cord enters theinguinal canal through the
deep inguinal ringDeep inguinal ring
Superficial inguinal ring
Lateral
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Inguinal canal
63
Medial
Superficial inguinal ring
The anterior wall is made up of the external
obliquemuscle throughout, and is reinforced
by the
internal oblique m. laterally.Thetransversus abdominus m.lies even
more laterally as part of the anterior abdominal
wall.
Lateral
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Inguinal canal
64
Floor
Spermatic cord
Medial
Lateral
The transversus abdominis and
internal oblique mm. combine to
form the CONJOINT tendon that
arches over the contents of the
inguinal canal
The conjoint tendon attaches to
the pubic crest, reinforces theposterior canal wall medially
and also forms the ROOF of
the canal
Conjoint tendon
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Posterior wall of the inguinal canal
65
Deep inguinal ring
Medial
The posterior wall is formed by transversalis fascia
(orange) throughout and the conjoint tendon (red)
medially. The wall is particularly weak over the deep
inguinal ring
Lateral
Conjoint tendon mediallyPosterior wall
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Floor of the inguinal canal
66
Floor
Medial
The floor is formed by an incurving of the inguinal ligament,
which is part of the external oblique muscle, forming a gutter.
(Medially it forms the lacunar ligament).
Lateral
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Roof and anterior wall of the
inguinal canal
67
Medial
The anterior wall of the canal is formed by external oblique muscle
(orange) throughout and by internal oblique muscles
(red/black/white) laterally. This wall is weak medially because of
the hole in the external oblique muscle (= superficial inguinal ring).
Lateral
Superficial inguinal ring
h l l
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Pressures on the inguinal canal
68
Lateral
Medial
Deep inguinal ring intra abdominal
pressure
Spermatic cord
Superficial inguinal ring
Conjoint tendon
= areas where reinforcement is present
Reinforcedanterior
wall by
internal
oblique m.
Reinforced
posterior wall
Pressure on
anterior wall
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Pressures in the inguinal canal
69
Lateral
Deep inguinal ring intra abdominal
pressure
Superficial inguinal ring
Conjoint tendon
Reinforced
anterior
wallReinforced
posterior wall
Weakness here
leads to direct
inguinal hernias
S.C.
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Deep Inguinal Ring inch above the ligament Midway between ASIS and the Symphysis
Lateralto the inferior epigastric vessels
Margins of ring give origin to the internal spermaticfascia
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Superficial Inguinal Ring Triangular defect in the aponeurosis of the externaloblique
Immediately above and medial to the pubictubercle
Margins give origin to the external spermatic fascia
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Mechanics of the inguinal CanalA potential weaknessA design to lessen weakness:
Oblique passageweakest areas lying some distanceapart
Anterior reinforcement by Int. oblique in front of deepring
Posterior reinforcement by Conjoint tendon behindsuperficial ring
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Mechanics of the inguinal Canal
Cont. On coughing/straining (defecation,parturition etc.) Int. oblique andtransversus abdominis muscles contract
f lattening the roof
canal isvirtually closed
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Inguinal hernias The posterior wall of the canal is particularly weaklaterally because of the deep inguinal ring
The anterior wall opposite the deep ring is reinforced
laterally by the internal oblique m.
A hernia (e.g. of small bowel) that comes through thedeep inguinal ring will have to travel along theinguinal canal as it cannot push into the reinforcedlayers of muscle in the anterior wall of the canaldirectly opposite the deep inguinal ring
74
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Inguinal hernias The anterior wall of the canal is weak medially wherethe superficial inguinal ring is situated
The posterior wall, opposite the superficial ring, is
reinforced medially by the conjoint tendon that isformed by fibres of the internal oblique andtransversus abdominis muscles
Abdominal contents cannot normally force themselvesthrough the superficial ring directly because of thereinforced posterior wall medially
75
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Indirect inguinal hernias Pass through the deep ring Travel along the canal
Exit the superficial ring above and medial to the pubictubercle .Since the incurved inguinal ligament formsthe floor of the canal, the contents of the canal couldnot emerge below or lateral to the public tubercle(useful in surgical diagnosis). An example is congenitalinguinal hernia.
Coverings of indirect hernias
76
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Coverings of indirect hernias Peritoneum Internal spermatic fascia
(from transversalis fascia)
Cremaster muscle & fascia(from transversus abdominis andinternal oblique mm.)
External spermatic fascia(from external oblique m.)
Superficial fascia
Skin
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Direct inguinal hernias If the posterior wall of the canal is weakened medially(e.g. by chronically increased intra-abdominalpressure), it can stretch and bulge out through the
superficial ring The contents of the hernia do not travel along the
length of the canal but push directly on the stretchedposterior inguinal canal wall and through the
superficial ring. Coverings of direct hernias
78
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Coverings of direct hernias Peritoneum Transversalis fascia
Conjoint tendon
External oblique aponeurosis
Superficial fascia
Skin
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Abdominal Quadrants Formed by two intersecting lines:Intersect at umbilicus.
Quadrants:
Upper left.
Upper right.
Lower left.
Lower right.
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Abdominal Regions
Divided into 9 regions by two pairs of planes:Vertical Planes:
Left and right lateral planes
= midclavicular planesHorizontal Planes:
Transpyloric plane:
Midway between jugular notch and
pubic symphysis (between xiphoid andumbilicus).
Intertubercular plane:
Through tubercles of iliac crests.
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Regions of the abdomen
R hypochondrial Epigastric L hypochondrial
R Lumbar Umbilical L Lumbar
R iliac Suprapubic/Hypogastric
L iliac
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Abdominal Regions Right and left hypochondriac:Contain liver
Epigastric:
Contains: liver, stomach, pancreas
Right and left lateral (lumbar):
Right contains ascending colon.
Left contains descending colon.
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Abdominal Regions Umbilical:Contains small intestine and transverse colon.
Right and left inguinal:
Right contains ileocecal junction and appendix.
Left contains sigmoid colon.
Hypogastric:
Contains small intestine, urinary bladder (full),pregnant uterus.
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Protuberance of the abdomen. The five common
causes (5F) Fat, Faeces, Fetus, Flatus And Fluid
Abdominal Hernias
Anteriolateral abdominal wall may be the site of
hernias Inguinal, umbilical and epigastric regions
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Common Sites
Inguinal HerniaUmbilical Hernia
Femoral Hernia Incisional Hernia
Less common Hernia Epigastric Hernia Recurrent Hernia
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Umbilical Hernia
Fascial defect at the umbilicus withperitoneal sac covered by skin
Paediatric umbilical hernias
Adult umbilical hernias
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Pediatric Umbilical Hernia Present in 10-30% of babies
80% close spontaneously by age 2
Indications for primary suture repair
Hernia present after ages 2-4
Large (5 cm) defect at age 1
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Adult Umbilical Hernia Increased intra-abdominal pressure Pregnancy
Obesity
Ascites
Differential diagnosis (rare)
Embryologic remnants
Metastatic cancer
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Adult Umbilical Hernia Symptoms relate to cosmesis, traction on the sac,
or trapped contents
Omentum
Small or transverse colon
Acute incarceration: reduction en masseproblematic
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Adult Umbilical Hernia Repair
Assess contents and manageappropriately based on viability
Open hernia repair
< 1 cm defect: primary suture repair > 1 cm defect: mesh repair lowers recurrence
Laparoscopic hernia repair: size of accessports often > hernia incision
Epigastric Hernia
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Epigastric Hernia
Fascial defect in supraumbilical linea alba Most < 1 cm
20% with multiple defects
Beware diastasis recti
Men: Women 2:1
Epigastric Hernia
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Epigastric Hernia
Contents Incarcerated preperitoneal fat or falciform ligament Peritoneal sac
Repair Open repair similar as for umbilical hernia Must palpate or visualize entire supraumbilical linea alba
Laparoscopic approach is suboptimal
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Spigelian Hernia
Defect through transversus abdominus andinternal oblique muscles
Occurs at junction of arcuate line and linea semilunaris Fascial defect 1-2 cm
Covered by external oblique aponeurosis
Spigelian Hernia
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Spigelian HerniaPresentation Lower abdominal swelling lateral to rectus
Focal discomfort/pain
May require imaging studies for diagnosis Ultrasound or CT
Repair: open or laparoscopic, on-lay mesh
I i i l H i
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Incisional Hernia
Bulge in region of scar from surgery orpenetrating trauma
Chronic wound failure Up to 20% of abdominal incisions
Subcutaneous sac may be more complex
Multi-loculated Contents adhesed within sac
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Incisional Hernia: Risk FactorsPrevious incisional hernia repair
Obesity
Smoking
Chronic lung disease
Diabetes
MalnutritionWound infection
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Incisional Hernia Repair
Fix conditions that promotedhernia occurrence
Open repair
Primary suture: < 52% recurrence Mesh: < 24% recurrence
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Common Clinical FeaturesThe features of all hernias are:
They occur at weak spotThey reduce on lying down or with direct
pressure
They have an expansile cough impulse
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ComplicationsUntreated hernia may develop following
complications:
a) intestinal obstructionb) strangulationc) incarceration
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ABDOMINAL WALL DEFECTS
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OmphaloceleMembrane sac arising from the umbilical cord
covers intestines
Outer membrane layer consists of amnion and
inner lining of peritoneum Size ranging from small->giant defects containing
liver, small and large bowel, stomach, spleen,ovaries, and testes
Associated with foreshortened bowel andmalrotation
Small abdominal cavity and pulmonary hypoplasia
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Gastroschisis No membrane coveringAbdominal wall defect typically 2-4cm diameter
Lateral to the right side of the umbilical cord Usually contains midgut and stomach
Thickened, atretic, and possibly ischemic bowel
Associated with malrotation
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ABDOMINAL WALL DEFECTSomphalocele gastroschisis
Membrane covered
1-15 cm defect size
Centre of the membrane Bowel-normal
Associated abnormalities-60%
Open defect
2-5 cm
Left of the defect Bowel-edematous,serositis
10%
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