Umbilical, paraumbilical and epigastric

Question 1

What is a paraumbilical hernia?

Answer 1

A paraumbilical hernia is a primary ventral hernia characterized by abnormal protrusion of intra-abdominal contents through one side of the umbilical ring/stalk.

Question 2

How do paraumbilical hernias in adults differ from umbilical hernias in childhood?

Answer 2

Paraumbilical hernias in adults are distinct from the umbilical hernia of childhood.

Question 3

Are paraumbilical hernias more common in women or men?

Answer 3

Much more common in women; F > M.

Question 4

Are paraumbilical hernias congenital or acquired?

Answer 4

Paraumbilical hernias are acquired.

Question 5

What are the predisposing factors for the development of a paraumbilical hernia?

Answer 5

Factors that increase intra-abdominal pressure include:
* Pregnancies & prolonged labour
* Ascites
* Obesity
* Large intra-abdominal tumours

Question 6

What contributes to the pathogenesis of paraumbilical hernias?

Answer 6

Structural features of the umbilical ring

Specifically, a weakness at the superior rim of the umbilicus

Question 7

What is structural features leads to weakness at the superior rim of the umbilicus?

Answer 7

Insertion of the lowest tendinous insertion of the rectus abdominis into linea alba, and attachment of the round ligament, urachus, and umbilical artery.

These attachments create areas of potential weakness in the umbilical region

Question 8

What do the two umbilical arteries become in an adult?

Answer 8

The medial umbilical folds

Question 9

What does the umbilical vein become in a child, and then in an adult?

Answer 9

The umbilical vein becomes the ligamentum teres in children, and later the round ligament of the liver in adults.

Question 10

What does the vitello intestinal duct contain in the embryo?

Answer 10

Gut

Question 11

What does the vitello intestinal duct become in children, and then in adults?

Answer 11

The vitello intestinal duct can be a persistent omphalo-mesenteric duct or Meckels in children. In adults it is obliterated or remains as a meckels diverticulum in 2% of the population.

Question 12

What does the falciform ligament contain?

Answer 12

The ligamentum teres/round ligament of the liver.

Question 14

What happens to the fibrous character of the umbilicus in the presence of a paraumbilical hernia?

Answer 14

The umbilicus retains its fibrous character within the linea alba but becomes effaced by the pressure of the hernia contents.

Question 15

What is the initial content of an early paraumbilical hernia?

Answer 15

Extraperitoneal fat.

Question 16

What do paraumbilical hernias contain as they get larger?

Answer 16

Omentum, and occasionally transverse colon or small bowel.

Question 17

Are paraumbilical hernias usually reducible?

Answer 17

No, they typically adhere to the sac and become loculated and irreducible.

Question 18

Fill in the blank: The umbilicus becomes effaced by the pressure of the hernia contents, creating an eccentric ‘________’ furrow.

Answer 18

half-moon

Question 19

In adults, what percentage of para/umbilical hernias are congenital umbilical vs acquired paraumbilical hernias?

Answer 19

10% of are congenital umbilical hernias
90% are acquired paraumbilical hernias

Question 20

How may umbilical/paraumbilical hernias present?

Answer 20

Asymptomatic, or localised pain +/- obstruction

Question 21

List four complications of para/umbilical hernias

Answer 21

Incarceration

Obstruction

Strangulation

Skin thinning/ excoriation/ ulceration/ discolouration/ necrosis (large hernias)

Question 22

How are para/umbilical hernias diagnosed? When is a CT indicated?

Answer 22

Generally a clinical diagnosis is adequate. A CT is indicated when the diagnosis is unclear or in the context of a complicated hernia.

Question 24

What non-operative measures are advised in management of peri/umbilical hernia?

Answer 24

Weight loss to reduce progression of the defect

Question 25

What non-operative measures are often ill-suited to the management of para/umbilical hernias?

Answer 25

Tapes, binders, and trusses: These measures can lead to skin infection or necrosis.

Question 26

How should repair of para/umbilical hernia be managed in patients with ascites?

Answer 26

Maximize medical management & avoid opening the sac intraoperatively

Question 27

How should repair of para/umbilical hernia be managed in patients on peritoneal dialysis?

Answer 27

Stop peritoneal dialysis and cover with haemodialysis for 6/52 post-op

Question 28

List four situations in which non operative management of para/umbilical hernias is appropriate

Answer 28

++ co-morbidities Malignancy/ malignant ascites Painless reducible hernias Asymptomatic hernias associated with ascites

Question 29

List the surgical principles of para/umbilical hernia repair

Answer 29

Para-umbilical hernias should be surgically repaired in fit patients Expose a fascial edge of 1cm, to ensure adequate fascial bites Close transversely Small defects can be repaired under LA For defects <2cm – No mesh (Mayo repair) > 2-3cm – Use mesh

Question 30

What is the prognosis/natural history of untreated para/umbilical hernias? What is the prognosis and natural history of both treated and untreated para/umbilical hernias in patients with ascites?

Answer 30

Tend to enlarge progressively over time Small neck \ incarceration & strangulation are common In pts with ascites: Necrosis/ infection/ rupture of untreated hernia has a mortality up to 30% M+M & recurrence are high after hernia repair Medical Rx of ascites periop is critical to minimize M+M

Question 31

How do you clinically differentiate between umbilical and paraumbilical hernias?

Answer 31

Umbilical hernias – Symmetrical bulge with the protrusion directly under the umbilicus Paraumbilical hernias – Half the fundus of the sac is covered by the umbilicus and the remainder is covered by skin of the abdomen immediately adjacent to the umbilicus.

Question 32

How does an umbilical hernia differe from exomphalos/omphalocele?

Answer 32

Exomphalos (omphalocele) is covered only by amniotic membrane, no skin.

Question 33

How does the management of umbilical hernias differ from that of paraumbilical hernias?

Answer 33

Umbilical hernias– May resolve spontaneously in young Paraumbilical hernias– Often require surgical intervention as they do not resolve spontaneously and has high incidence of incarceration/ strangulation.

Question 34

Define: umbilical hernia

Answer 34

A congenital defect in which the peritoneal sac protrudes through a patent umbilical ring and is covered by normal skin

Question 35

What is the incidence of umbilical hernias in infancy and adulthood?

Answer 35

5-10% of Caucasian infants have these at birth. 10% of these will be carried on into adulthood. The rest will spontaneously resolve.

Question 36

When are umbilical hernias most easily noted in infants? How often do they incarcerate? How should they be assessed?

Answer 36

Umbilical hernias in infants are most commonly noticible when the child is coughing, crying or vomiting. They rarely incarcerate. Umbilical hernias in infants can be assessed clinically, with or without ultrasound.

Question 37

What percentage of umbilical hernias will close within one month of birth? By what age are most infantile umbilical hernias closed?

Answer 37

30% of umbilical hernias will close w/in 1 mth of birth. They rarely persist beyond 3-4 yrs

Question 38

What is the definition of an epigastric hernia?

Answer 38

Abnormal protrusion of intra-abdominal contents (usually preperitoneal fat +/- small sac of peritoneum) through the linea alba anywhere b/w xiphisternum and umbilicus

Question 39

In what gender and age group are epigastric hernias most common? What percentage occur off the midline? What percentage are multiple?

Answer 39

M>F Most common b/w ages of 20-50 80% occur just off the midline, 20% are multiple

Question 40

Epigastric hernias can be congenital or acquired. How do they develop?

Answer 40

Epigastric hernias evelop through: (1) Foramina of the small paramidline nerves/ vessels, or (2) A congenital weakness in the linea alba Perperitoneal fat is forced out of the canal, followed by adherent peritoneum Usually small (1cm), irreducible and in 20% of cases, multiple!

Question 41

How do epigastric hernias present? What is the differential diagnosis?

Answer 41

Asymptomatic Vague upper abdo pain & tenderness +/- nausea. Differential diagnosis PUD/ GORD, Biliary disease Usually palpable in non-obese pts (but hard to see)

Question 42

What investigations are necessary for epigastric hernias?

Answer 42

Imaging not necessary, but may help to detect multiple defects. US is often advisable (for marking)

Question 43

What are the principles of epigastric hernia repair?

Answer 43

General anaesthetic Repair recommended to relieve symptoms Mark preoperatively (as may reduce with anaesthetic)   Surgical Approach - open or TAPP Small (<2cm) – Primary closure as below Large (>6cm) – Use mesh (open or lap approach) Primary closure Single defect – Mayo repair. Defect closed primarily after the contents are dissected free Multiple hernias Keel repair. Vertical skin incision, excise preperitoneal fat, repair each defect primarily, then keel repair of linea alba. or Incise linea alba to incorporate multiple hernias into one defect then close longitudinally

Question 44

What is a keel repair?

Answer 44

Question 45

Epigastric hernias are prone to incarceration. What do they normally contain?

Answer 45

Pre-peritonea or omental fat.