Abdominal Hernias Practice Essentials, Background, Anatomy.Inguinal hernia. The pinchcock action of the internal ring musculature during abdominal muscular straining prohibits protrusion of the intestine into a patent processus.Muscle paralysis or injury can disable the shutter effect.Infertility is the inability to conceive after a long period with unprotected sex.It also refers to the biological inability of a person to contribute to conception.In addition, the transversus abdominis aponeurosis flattens during tensing, thus reinforcing the inguinal floor.A congenitally high position of the aponeurotic arch may preclude the buttressing effect.Neurapraxic or neurolytic sequelae of appendectomy or femoral vascular procedures may increase the incidence of hernia in these patients.Clinical presentations suggest repetitive stress as a factor in hernia development. How To Update Textblock Wpf Tutorial more. Increased intra abdominal pressure is seen in a variety of disease states and seems to contribute to hernia formation in these populations.Elevated intra abdominal pressure is associated with chronic cough, ascites, increased peritoneal fluid from biliary atresia, peritoneal dialysis or ventriculoperitoneal shunts, intraperitoneal masses or organomegaly, and obstipation.See the images below.Other conditions associated with an increased incidence of inguinal hernias are exstrophy of bladder, neonatal intraventricular hemorrhage, myelomeningocele, and undescended testes.A high incidence 1.The rectus sheath adjacent to groin hernias is thinner than normal.The rate of fibroblast proliferation is less than normal, and the rate of collagenolysis appears increased.Sailors who developed scurvy had an increased incidence of hernia.Aberrant collagen states eg, Ehlers Danlos, fetal hydantoin, Freeman Sheldon, Hunter Hurler, Kniest, Marfan, and Morquio syndromes, have increased rates of hernia formation, as do osteogenesis imperfecta, pseudo Hurler polydystrophy, and Scheie syndrome.Acquired elastase deficiency also can lead to increased hernia formation.In 1. 98. 1, Cannon and Read found that the increased serum elastase and decreased alpha.The contribution of biochemical or metabolic factors to the creation of inguinal hernias remains a matter for speculation.Inguinal hernias are commonly classified as either direct or indirect.Issuu is a digital publishing platform that makes it simple to publish magazines, catalogs, newspapers, books, and more online.Easily share your publications and get.Clinical Trials For Klinefelter Syndrome Pictures' title='Clinical Trials For Klinefelter Syndrome Pictures' />A direct inguinal hernia usually occurs as a consequence of a defect or weakness in the transversalis fascia area of the Hesselbach triangle.The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon.An indirect inguinal hernia follows the tract through the inguinal canal.It results from a persistent processus vaginalis.The inguinal canal begins in the intra abdominal cavity at the internal ring, approximately midway between the pubic symphysis and the anterior superior iliac spine, and courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle.The hernia contents then follow the tract of the testicle down into the scrotal sac.Femoral hernia. A femoral hernia follows the tract below the inguinal ligament through the femoral canal.The canal lies medial to the femoral vein and lateral to the lacunar Gimbernat ligament.Because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated.Perihernial fasciae or muscles may be malformed.Umbilical hernia.An umbilical hernia occurs through the umbilical fibromuscular ring, which is usually obliterated by age 2 years.See the image below.They are congenital in origin and are repaired if they persist in children older than 2 4 years.Although umbilical hernias in children arise from failed closure of the umbilical ring, only one in 1.Adult umbilical hernias occur through a canal bordered anteriorly by the linea alba, posteriorly by the umbilical fascia, and laterally by the rectus sheath.Proof that umbilical hernias persist from childhood to present in adulthood is only hinted at by an increased incidence among black Americans.Multiparity, increased abdominal pressure, and a single midline decussation are associated with umbilical hernias.Congenital hypothyroidism, fetal hydantoin syndrome, Freeman Sheldon syndrome, Beckwith Wiedemann syndrome, and disorders of collagen and polysaccharide metabolism such as Hunter Hurler syndrome, osteogenesis imperfecta, and Ehlers Danlos syndrome, should be considered as possibilities in children with large umbilical hernias.Richter hernia. A Richter hernia occurs when only the antimesenteric border of the bowel herniates through the fascial defect.This hernia involves only a portion of the circumference of the bowel.Thus, the bowel may not be obstructed, even if the hernia is incarcerated or strangulated, and the patient may not present with vomiting.A Richter hernia can occur with any of the abdominal hernias and is particularly dangerous in that a portion of strangulated bowel may inadvertently be reduced into the abdominal cavity, leading to perforation and peritonitis.Incisional hernia.An incisional hernia is an iatrogenic condition that occurs in 2 1.Even after repair, recurrence rates approach 2.Spigelian hernia.A spigelian hernia occurs through a defect in the spigelian fascia, defined by the lateral edge of the rectus abdominis at the semilunar line from costal arch to pubic tubercle.Abnormal orientation of the semilunar and semicircular lines, along with obesity, increased intra abdominal pressure, aging, and rapid weight loss, leads to the production of spigelian hernias.There are two subtypes of spigelian hernia, interstitial and subcutaneous.Distinguishing between these subtypes helps optimize the surgical approach when indicated and is best done by means of computed tomography CT.Obturator hernia.An obturator hernia passes through the obturator foramen, following the path of the obturator nerves and muscles.There is a strong female preponderance female to male ratio, 6 1, because of a gender specific larger canal diameter this hernia is also much more likely to occur in the elderly.Because of its anatomic position, an obturator hernia more commonly presents as a bowel obstruction than as a protrusion of bowel contents.Other hernias. Aberrant formation of the decussations of the linea alba, leading to a midline pattern of single anterior and posterior lines, predisposes to the formation of epigastric hernias epiploceles.Internal supravesical hernias probably arise from a congenital fascial deficiency.Perihernial fasciae or muscles may be malformed in lumbar hernias.Interparietal hernias are often a product of ectopic testicular descent.Multiparity and age produce laxity of the pelvic floor to cause perineal hernias.Congenital abdominal wall defects.The underlying embryogenic factor in omphalocele and gastroschisis is deficient closure of the developing anterior wall at the umbilical stalk.Variations in lateral fold migration can result in both of these defects.In addition, most children with omphalocele and all children with gastroschisis have intestinal malrotation their extracoelomic location precludes normal attachment of the intestines to the posterior peritoneum.Improper development of other portions of the abdominal wall leads to specific anomalies.In 1. 96. 7, Duhamel proposed that maldevelopment of the superior cephalad fold of the abdominal wall leads to the thoracic, sternal and diaphragmatic, and abdominal wall defects that make up the upper midline syndrome pentalogy of Cantrell.This syndrome includes a bifid sternal cleft, an anterior diaphragmatic defect, an anterior pericardial defect, an epigastric omphalocele, and congenital cardiac defects.Maldevelopment of the inferior caudal fold produces pelvic, hindgut, sacral, genital, and bladder defects.Lower midline syndrome includes a hypogastric omphalocele, exstrophy of the bladder or cloaca, vesicointestinal fissure, colonic atresia, imperforate anus, sacral vertebral defects, and often meningoceles.Lateral fold maldevelopment results in omphalocele see the image below, as well as gastroschisis.It has been postulated that an omphalocele results from persistence of the umbilical stalk in the somatopleure.Approximately 2. 0 of infants with omphaloceles have an associated chromosomal abnormality eg, trisomy 1.Klinefelter syndrome.
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