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06-08-2008, 08:23 AM
Definition: Hernial protrusion through postoperative scar, Except a scar of operation for hernia Recurrent H.
Aetiology: Of incisional hernia = of recurrent hernia = causes of burst abdomen.
1- Pre-operative: (patient's fault)
a) Debilitating disease e.g. Malignancy, T. B., Diabetes Mellitus and anaemia delay healing.
b) Immunodeficiency disease. Infection.
c) Obesity Infection d) Chronic chest infection ­ I.A.P.
2- Intra-operative: (surgeon's fault) ( local causes)
a) Inadequate surgical technique e.g. Too tight or too lose suturing, nerve injury or haematoma.
b) Septic surgery e.g. operation for peritonitis.
3- Post operative: (Nurses & patient's fault)
a) Post operative distention. b) Hurried ampulation.
c) Wound infection. d) Persistent pre-operative problems.
Treatment:
1. Simple anatomical aposition: Excision of the sac and regaining of normal anatomical layers.
2. Complex apposition:
a- Keel operation: Sac is not opened but invaginated by successive raws of inverting stitches. The sac will project into the abdomen like a keel of boat.
b- Cattel's 5 layers repair: We do 2 lateral incision in the ant. rectus sheath dividing it into med. & lat. flaps. Then, the sac is opened then suture:
1- Edges of the defect at the neck.
2- Edges of the sac at the fundus.
3- Medial flaps of rectus sheath.
4- Rectus muscles together.
5- Lat. flaps of rectus sheath.
The complex apposition techniques should be considered obsolete and of historical interest only.
3- Hernioplasty by fiber mesh or net closure: The mesh is put between the rectus muscle and posterior rectus sheath in cases of hernia above umbilicus. Below the umbilicus the mesh is placed in preperitoneal space. These techniques are now the method of choice.
Ä Postoperative treatment
Gastric decompression and intravenous fluids are employed, and nothing by mouth allowed until the bowels have functioned.
Early ambulation and gentle physical exercise are to be encouraged. The patient should not do strenuous exercise for several weeks.
Ä Results of treatment
Most series report recurrence of the hernia in between 30 and 50 per cent of cases except where mesh inlay techniques have been employed in specialist centers, where recurrence rates may be as low as 10 per cent.
m Divarication Of The Recti Abdominis
Ä Aetiology. Divarication of the recti abdominis is seen principally in elderly multiparous patients and those with long standing abdominal distension.
Ä Diagnosis. When the patient strains, a gap can be seen between the recti abdominis through which the abdominal contents bulge. When the abdomen is relaxed, the fingers can be introduced between the recti.
Ä Treatment. An abdominal belt is all that is required. There is no risk of strangulated intestinal contents. A similar condition is seen in babies, only the divarication exists above the umbilicus. No treatment is necessary; as the child grows a spontaneous cure results.
SOURCE: DR. AYMAN SALEM'S BOOK
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