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LAPAROTOMY

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SURGICAL INCISIONS

MID LINE INCISION

  • Through linea alba
  • Easier above umbilicus , as recti are wide apart
  • Scar may be weak Epigastric hernia may take place

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SURGICAL INCISIONS

PARAMEDIAN INCISIONS

  • One inch lateral to midline
  • May be supra or infra umbilical
  • Nerves to rectus are entering from lateral side, so safe

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SURGICAL INCISIONS

PARA RECTAL INCISIONS

  • Not favoured
  • Access provided is very small
  • As nerves to rectus are in close viscinity

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SURGICAL INCISIONS

VERTICAL INCISION

  • Through rectus abdominis
  • Not favoured
  • Nerves are likely to be cut

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SURGICAL INCISIONS

GRID IRON ( M c burney’s ) INCISION

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HERNIA

Hernia

Sac

Neck

Coverings

Reducible

Strangulated

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UMBILICAL HERNIA

  • Physiological hernia

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UMBILICAL HERNIA

  • Congenital umbilical hernia

Exomphalos

Omphalocele

  • Acquired infantile umbilical hernia

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UMBILICAL HERNIA

Acquired umbilical hernia

  • Para umbilical
  • Commonly seen in women

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DIVARICATION OF RECTI

  • In female
  • Abdominal muscles become weak due to multiple pregnancy
  • Recti are wide apart in upper part

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  • Femoral hernia
  • Incisional hernia
  • Lumbar hernia
  • Gluteal hernia
  • Perineal hernia
  • Obturator hernia
  • Ischiorectal hernia
  • Sciatic hernia

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SPIGELIAN HERNIA

  • Spontaneous lateral ventral hernia below the umbilicus and lateral to the rectus muscle, at junction of vertical semilunar line and horizontal semicircular line

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  • 90% located 0 - 6 cm above anterior superior iliac spine (Spigelian belt of Spagel)

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SPIGELIAN HERNIA

  • Named for Adrian vander Spieghel: Flemish anatomist, (1578 - 1625)
  • Characteristics:�    - median age = 50 years�    - more common in males than females�    - more common on right side than left side

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LUMBAR HERNIA�

  • External oblique, iliac crest, lattissimus dorsi
  • Acquired (55%) trauma or renal surgery
  • Congenital�Superior ( Grynfelt-lesshaf triangle )    

Inferior ( Petit's hernia )

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FEMORAL HERNIA

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EPIGASTRIC HERNIA

  • Linea alba defect in upper midline
  • 5% of hernias

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UMBILICAL HERNIA�

  • Failure of closure of umbilical ring
  • Common in males, and premature infants
  • Acquired in adults with cirrhosis, obesity, ascites, malnutrition

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INCISIONAL HERNIA

  • 10% of cases
  • More common in females
  • Unrecognized or late dehiscence
  • Etiology:   
    • wound infection     
    • technical errors
    • increased intra-abdominal pressure �

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INCISIONAL HERNIA

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OBTURATOR HERNIA

  • 0.1% of hernias, 0.2% of bowel obstructions
  • Greater incidence in females than males ( 9:1)
  • Frail women in 7th or 8th decade
  • More common on right 20% bilateral
  • Medial groin pain secondary to obturator nerve impingement

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PERINEAL HERNIA

  • Complication of abdominal-perineal resection
  • Has a distinct sac, i.e. not a rectocele (pelvic floor relaxation)
  • Most common in females

 

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SCIATIC HERNIA�

  • Gluteal hernia via greater sciatic notch
  • Presents with sciatica

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  • Thoraco epigastric vein connects

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Lateral thoracic vein ( tributary of axillary vein )

with

Superficial epigastric vein ( tributary of femoral vein )

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UMBILICUS

ANOMALIES

  • Urinary fistula

Due to patent urachus

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UMBILICUS

  • Faecal fistula

Persistence of vitello intestinal duct which communicate between primitive gut & secondary yolk sac

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MECKEL’S DIVERTICULUM

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  • Persistence of proximal part of vitellointestinal duct
  • Mesenteric border of ileum
  • 2 feet proximal to ileo caecal junction

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UMBILICUS

EXOMPHALOS

Persistence of physiological herniation of mid gut loop

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ENTEROCYSTOMA

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  • Persistence of intermediate part of vitello intestinal duct
  • Swelling may bulge through umbilicus

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RASPBERRY RED TUMOUR

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  • Persistence of distal part of vitellointestinal duct
  • May discharge mucus at surface
  • Surface may evaginate producing tumour

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UMBILICUS

ECTOPIA VESICAE

Failure of development of ant. Abdominal wall below umbilicus

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UMBILICUS

REFERRED PAIN

  • Supplied by T10
  • Also supplies ovary, testis, kidney, ureter & appendix
  • Pain from these organs may be referred to umbilicus

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UMBILICUS

WATER SHED LINE

  • Transitory line across umbilicus
  • Demarcates direction of flow of superficial lymphatics and venous blood
  • They never cross this line

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UMBILICUS

  • PORTO CAVAL ANASTOMOSIS

Between

para umbilical veins ( portal )

&

Sup. Epigastric & thoraco epigastric

Veins of ant. Abdominal wall ( Systemic )

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UMBILICUS

CAPUT MEDUSAE

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Formation of dilated veins around and radiating from umbilicus in PORTAL OBSTRUCTION

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APPENDICITIS

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CHOLECYSTITIS

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RENAL COLIC

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