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Good evening, everybody. Um I'm speaking, I'm, I'm speaking from ***, medical Student in the University of College of Medicine and I'm mod in this session. And with me, I have Doctor Alexander, I would uh read this profile in the be OK. So doctor Alexander Ab ABIM Maram is a GP I surgeon by practice from three, currently serving as a research fellow at the Est Global Surgery Foundation. He is a graduate of the School of Medicine in 2020 with invaluable experience as a practitioner in general surgery and acute surgical care at the three. Doctor Alexander's expertise in NK is of notable significance, having performed multiple su successful surgeries during his general practitioner. Doctor Alexander's passion extends beyond the operating room as is not just a deep seated interest in specializing in general surgery and acute surgical care. All the while maintaining a eas focus on the global surgical landscape is going to bridging the gap in health care, accessibility, resonates deeply with the experiences including leading surgical teams in undeserved communities. All right. So, GRE and everybody. So um do Doctor Alexander, I think we can have you and I miss today. Um The first session was really a light new one and I believe that today um everyone is ready to learn from you and we look forward to um look forward to what you have for us today. So um please sir, you can have the floor. Thank you. I mean, um welcome everyone. Uh So this is going to be our second and last uh session on uh webinar about abdominal uh hernias. Let me try to share my screen with everyone. Can everybody see my screen? All right. OK. So um we are going to be delving in, in abdominal um hernias and we're going to be picking off uh from where we left off on part one the past uh two weeks ago. So, uh as a recap, maybe it's uh much better to discuss the classification of hernias. Now, um in your tender and your uh career, you'll come across multiple ways of classifying abdominal hernias. This is one I have chosen and I have found to be more practical. This is a classification by the European Hernia Society and uh this is more anatomical and more practical uh approach to hernia classification. Now, broadly hernias will be classified internal and external hernias. Internal hernias are the ones that will happen within the cavities and not protruding into the um outside world. While um external hernias will be protruding from the abdominal uh canal and then uh into the um external world. So, um uh external hernias will then be broadly classified into groin hernias and ventral hernias. Groin hernias will include inguinal hernia and femoral hernia. While the ventral hernias will include epigastric hernia, umbilical hernias, bian hernia, incisional hernia and lumbar hernia. Now, mind you, uh, the term ventral means anterior, but you'll have lumbar hernias, which are usually on the uh la posterolateral side of the abdomen. And while uh inguinal and femoral hernias are still on the ventral side of the hernias, they're classified as groin hernias. This is much more for practicality rather than uh just anatomic location, I guess. All right. So we've discussed inguinal hernia uh on our previous session. Now, let's move on with uh femoral hernia. Now, uh a femoral hernia will be the protrusion of abdominal structures through the uh femoral canal. Now, naturally, femoral canal is made up of inguinal canal anteriorly, Laar ligament, uh medially, uh laterally, you'll have the um uh femoral vein and then posteriorly you'll have the peroneal uh ligament. Now, as you can see, it's more of a tubal kind of structure with uh a very narrow opening and a very hard structure such as the uh pubic bone bordering it. Now, naturally, the uh femoral canal uh will house um three way three structures which is the vein, the artery and the nerve. Usually in med school, we used to use the, the acronym van for vein artery and nerve. They're all femoral vein, femoral artery and femoral nerve. There's also another way of uh remembering it, which is the navel. So it will be the nerve, the artery, the vein and then the empty space or sometimes the lymph node, you see the screen structures. These are the lymph nodes that might occupy it. Now, it's a very narrow space and uh what, whichever structure might uh protrude through here as you can see, it will most likely strangulate or uh incarcerate. Now, uh the other, the other picture uh is a pictorial uh presentation of a laparoscopic view. So you see the structure, the with the, the letter A is the inguinal ligament. Let the B is the Laar ligament and look how sharp the edge is and how very narrow the space is cause this is the empty space where the hernia would naturally occur. You see that little structure that is the lymph node and then these are the iliac vessels covered with the fatty tissue which are just entering and then, then they will turn into the uh femoral artery and the vein. Now, this is the pubic arch that is going down, which is the term c. Now, sometimes you, you might have a bowel loop coming in into the uh femoral hernia. But most of the time, uh you will find what is termed as a Richters hernia. So now what the Richter's hernia is, is that because the space is very narrow, you might not find the whole loop entering, but you'll might find uh the wall, at least the anterior uh portion of the intestinal luke might enter into that uh space and then there will be strangulation and then later on uh gangrenous formation, gang uh gangrene formation and then perforation. And then this is one of the most uh dangerous and uh um uh risky hernias that you might have. Now, there are certain risk factors which might favor um femoral uh hernias as you've noted, uh as we've noted before earlier on, our previous discussion is that groin hernias are one of the most common types of hernias. Out of them, the inguinal hernias will be the most common. Next, most common would be the uh femoral hernias constituting about uh 75% will be inguinal hernias somewhere around 10%. Uh would be uh your 10 to 15% will be your femoral hernias. Now, femoral hernias are more common in females and then that has to do with their pelvic structure. The wider the structure, the more uh spacious it would be for abdominal organs to kind of descend through that uh defect. All right. So, diagnosis. Now, uh this is one of the hernias which uh uh which is prone to a lot of uh errors and it will often lead to delays in diagnosis and treatment. Now, mm anatomically or at least physically on physical inspection. The hernia will appear below and lateral to the pubic tubercle and it lies in the upper part of the leg rather than the lower portion of the abdomen. This is to differentiate between the direct inguinal hernia and uh your femoral hernia. Now, the reason it's under diagnosed is that because it's a coveted area and you really just tend to favor on the or err on the side of the patient's privacy. You rarely um do as a regular physical ex uh physical uh examination and then you might miss it and usually the hernia is uh it will quickly become irreducible and it will lose its cuff impulse. This is due to the tightness or at least the narrowness of the defect. And uh the size is usually about 1 to 2 centimeters and it's usually easily mistaken for lymph node. And the reason for that is your typical patient will be somewhere, some old uh lady uh coming with a little swelling and pain there. And you might attribute that to uh malignancies as they are very common in old age. That is usually the gynecology malignancies. Now, as it increases in size, sometimes it might be reflected superiorly and it might be indistinguishable from the um the, the medial or direct hernias. But you will just have to delineate your inguinal uh ligament and then your direct hernia will occur above that inguinal ligament. And if it's a femoral hernia, it will just arise from, from below it. And that's usually how you differentiate it in your physical exams. All right. This, so this is a pectoral presentation. As you can see here, you'll see that the patient might have uh well, actually has a swelling below the inguinal ligament on the left side. While it is, it is above the inguinal ligament on the uh right side o on the patient's right side. So this is a direct inguinal hernia here while this is a femoral hernia here. Now, your differential diagnosis will include your direct inguinal hernia, lymph nodes, a pheno varix, femoral aneurysm. So as abscess and sometimes very rarely a rupture of the ductal longus with hematoma. Now, usually this is a physical or an athlete's uh diagnosis. All right. So management. Now, uh we've discussed on the principles on the previous um session. So I'm not going to go too deep into the principles of the surgeries here. But one of the ones that I would reiterate is that the narrower, the defect, the more uh urgent or the more emergent the case would become. So because femoral hernias or the defect of a femoral hernia is very small, there is no alternative uh management rather than surgery. So, and even the surgery is actually taken uh with some sort of urgency. Now, there are three open approaches which are still in practice uh till date and then sometimes appropriate cases can be managed laproscopic. It's uh very rarely that you'll see uh a hernia managed laparoscopically in uh low and middle income countries. But it has been uh the mainstay uh or at least is becoming the mainstay in majority of the developed nations. So, the surgical approach are three, like I've said, so we could say the low inguinal or high approach, you, the low approach is known as the low coid approach. So what you'll do is you'll do a horizontal incision which you see in this color here, right on top of uh the defect or right on top of the swelling. Now, usually this approach is favored when you're doing an elective surgery where there's no sign of an urgency and where you know that there is no incarceration or any uh nonviable bowel uh for you to encounter. Now, once you've noticed the sac, the hernial sac, you will have to just to just push everything back in, in total, including the sac and then it is advised to use a mesh plug here so that you can reinforce the, the defect and uh you can reduce the rate of recurrence. Now, you have to keep in mind there are a lot of uh vascular structures here. More importantly, you will have the femoral vein, which is right in approximation to your defect and you have to take care of that. And there's also an internal division of an internal iliac vessels right inside. Sometimes when you push it, you just don't need to, you need to be uh a little bit careful. Now, an inguinal approach also known as the Lofa approach is you'll do the incision just like what we talked about in the inguinal hernias. And then it will all go down up until the um transversalis FAA. And then that transversalis fa is opened and then the bowel is just pulled back uh with its sac and it's peritoneal covering. And then from then the facial um, structures are uh approximated and sometimes a plug mesh might be used. Uh and then the most favorable in emergency cases is what we would call the MC M Caity approach or the high approach. Now, what you would do here is classically it used to be a vertical incision, the one you see here. But now currently, what we're doing is we're doing a lateral incision right around the API line and then we reach until the rectus muscles see and then the muscles are bluntly uh pushed to the side and then you will have to enter into the abdomen. And then at this point because it's an emergency case, you will have a gangrenous uh bowel where you need to do resection and anastomosis. And then after that, it's not advisable to do a, a mesh repair in a dirty wound. So much better to just do uh the correction of that bowel and then uh do as much reapproximation as you could do to the tissues using a nonabsorbable suture. But then also sometimes some surgeons tend to choose um uh uh to re uh to do a, a re reinforcement surgery later on using mesh repair. Now, the other picture is just showing you where the ports might go in to do an uh, laparoscopic approach. Here. You'll just go transabdominal and you'll enter right into the abdomen and then try to notice the defect with, uh, the, the sac and then pull everything out, push in the mesh repair and then, uh, try to close the defect as much as possible. All right. So that was about uh femoral hernias. Now, let's move on to uh the ventral hernias. Now, like I said before, the term ventral uh hernia refers to the anterior abdominal wall. However, this classification which was chosen by the European Hernia uh hernia society in about 2009, it is more of a practical one. So you will see uh hernias that are not occurring uh anteriorly per se like the lumbar hernias. And we already know the list and we'll try to go to through these uh hernias, uh one by one and at least I'll try to press on the most pressing and important cases that you might come across uh very commonly. Now, umbilical hernias, uh we've discussed before as to the causes of an umbilical hernia. Now, uh the umbilical defect is present at birth and then this defect is due to structures passing through it in utero. And this is part of the reason why the weakness in the abdomen occurs in an umbilical hernia, but the umbilical uh stamp heals right away within the first week of birth, uh as the umbilical cord is not, not necessarily uh or not no longer present. Now, this process may be delayed leading to the development of a herniation in the neonatal period. However, even if it's closed in the adult uh period, it might stretch and reopen. So, let's see, uh the umbilical hernia in two different situations. So, in the neonatal period, this is actually one of the most common uh hernias and it can occur in up to 10% of infants. You will see a higher incidence in premature babies. Uh The hernias usually occur within the first few weeks of birth and they're usually symptomless. And then the typical case or the typical scenario is a mother will just bring her two week old uh neonate uh complaining of a swelling which she notices while the child is crying or straining. Uh But then it reduces and then the child will be uh symptomless, just playing and very happy child. Rarely you might encounter uh strangulation or at least intestinal obstruction symptoms, which is very rare to see uh before the age of three. Now, sexes are equally uh affected. However, it uh it has its uh race predilection, you'll see uh umbilical hernias at eight times higher uh in black Children rather than in white. Now, uh treatment option is we do conservative treatment up until two years of age because uh 95 of 95% of those cases will actually resolve spontaneously and you'll only operate on those five remaining cases which will actually stay beyond the second years of age. Because if they, if it doesn't close by the second year of age, it, it is highly unlikely that it will resolve on its own. And because of the deposition of all those fibrous tissue because the baby is growing, uh the hernia might be uh predisposed to strangulation. So at this time, uh it uh a decision to do surgery is made. Now how we do the surgery is, as you can see from this picture, a small Laar or a curved incision is made below the umbilicus and then the, the sac is identified. And as you can see, and then maybe if there's any ations, everything is uh uh is sliced. And then usually the practice is to just push all the content including the sac. And that's, that remains the, the practice. But sometimes if it's large enough, you might just need to open the sack, see the content and then reduce the contents and then uh reduce the excess sac uh as in excise, the excess sac and then uh close it with suture and then return it back in. Now, we never use nonabsorbable switches in Children. We always use in uh absorbable suture and then they're usually closed using interrupted uh stitch. All right. So let's come to umbilical hernias uh in adults. Now, conditions that cause stretching and thinning of the midline raphe or the linear alba are usually the main causes of umbilical hernia. In adults. These causes could be uh multiple pregnancies, obesity and liver disease with cirrhosis. For you, you might see have a patient with severe SI TS. Now, all of these will predispose to the reopening of the umbilical defect. So, uh anatomically speaking, it's not the defect that's uh opening. It's usually just the median, uh the median raphe immediately adjacent to it. Most of the time you'll see it's above the true umbilicus, usually most of the time. So because of this, the term, a paraumbilical hernia has been deemed uh to be uh applicable to umbilical hernias occurring in adults. Now, the defect is rounded and well defined with fibrous margins and uh sometimes it could get very large to include a huge amount of the bowel structures. So usually, uh you'll have a patient which is usually commonly overweight or at least having signs of cirrhosis with a very thin and attenuated midline RB is typically slightly to one side, uh and might look like a crescent shape. Women are affected more uh commonly than men. And usually this has to do with m multiparity or at least multiple pregnancies. And uh most patients will complain of pain due to tissue tension, especially as it increases in size. And then the bowel will start to be involved or at least contained within the sac. Now, as the hernias become very large, the overlying skin might actually be thin stretched and even uh develop dermatitis. So this is a picture you see uh down here a picture of a very huge uh umbilical hernia. Um So as you can see, uh a first note, the girth of the individual, it looks like this is a very obese uh individual that is being operated on uh within that hernial sac. You see, like even if the content is big, the defect is still small, relatively compared to the def to the size to the abdomen, or at least to the content that's coming out here. So at this point, it has become irreducible and I believe that there is bowel here. But note that the patient, the surgeon has actually taken some part of the skin uh from the the site. This is what we call the wedge resection. And usually because this uh hernia has stayed too long in the skin, there might be just excessive uh excessive cough, holding of the the skin. So you might need to take that so that you can be have a clean and very tight abdominal skin later on. So the defect will be open, the, the bowel will be returned, the excess sac will actually be excised and then the the defect will be closed somewhere around here and then pushed back in. And then this will be reinforced by a mesh now, like I said before, the treatment. And this is also uh before I forget a laparoscopic view and you can see the defect here. So the content has actually been reduced. So you're just seeing the defect and then the overlying facial and skin here, uh notice how it is just adjacent to the true umbilical stump. This is the true umbilical stump and it's not occurring there. It's just occurring in the midline raphe, right. Adjusting to it. So surgery could be performed open as you can see or laparoscopically. And then it's pretty much straightforward like we've discussed in the pediatric cases. All right. Next up, um is going to be epigastric hernias. These are the hernias you will see in a very fit adult male. Uh Now these hernias will arise through the midline roughy. Now, by definition, an epigastric hernia will extend anywhere from your xi sternum up until the cissus pubis. However, another name has been dubbed to hernias occurring in the umbilical region. That is the paraumbilical hernias or umbilical hernias. So, usually epigastric hernia will be anywhere from the ZYN up until the uh umbilical region. Now, there are two hypotheses as to why an um uh epigastric hernia occur or like we said before, why the there is a weakness in that structure of the abdomen. One is structures passing through it. So there are very small, tiny vessels that what might pierce the linear albo. And then this could be the reason for the defect. This is one hypothesis. Another hypothesis is just a weakness due to abnormal decussation of the neurotic fibers. And then usually this is related to uh heavy uh physical activity. Now, epigastric defects are usually less than one centimeter and uh from multiple uh epigastric hernias that I've operated on. The biggest I have found is about 1.5 centimeters and it could just fit my index finger into that defect. But usually the, regardless of their tiny def the, the tininess or at least the smallness of these defects, they are actually uh you'll have multiple patients just complaining of symptoms. Now, the reason for that uh is uh uh is that it will the extraperitoneal structures, usually you'll just have extraperitoneal fat with those uh defects. You'll never have a bowel uh occurring in an epigastric occur, especially in a tiny one. There was a case that I've handled, uh which actually involved uh some bowel, but that was a very huge one and that was a very uh must paras uh lady. And then we dubbed it to be a paraumbilical hernia later on. But in an epigastric hernia, the typical case because the defect is very small, you can, it can only fit the extraperitoneal fat. Now, because the defect is very tiny, the fat will get very nipped quick and then um infarction will occur that infarction will bring about severe pain for about 2 to 3 days and then a septic cats will try to take place and then the pain might resolve. And then after excessive physical activity again, yet another extraperitoneal fat will get trapped into that defect again. And then the patients will have a continuous history of this type of pain. Now, usually what it would look like is that the fat will just come out but then bulge out and then it might not return. So it might look like a mushroom. Now, more than one hernia might be present. And that's actually the most common cause of recurrence or at least failure is just to identify the second defect. And then the patient might come with a again another swelling and then the same symptoms. So, like I said, your typical patient is a fit healthy man aged between 25 and 40 years of age, the hernias can be very painful. Even if the swelling is the size of a pea, the pain might mimic that of a peptic ulcer. But you should not uh ascribe uh the pain to the hernia until. So you've actually done a G I pathology to exclude peptic ulcer disease. A soft midline swelling is actually indicative of uh epigastric hernia and it may be locally tender. And because of that narrow neck, you might not have any cuff impulse and then the pain, it's usually irreducible. All right treatment. Now, technically speaking, because it's usually just involving the extra peritoneal fat. Clinically, it might not be of any danger. So, a very small epigastric hernias have known to disappear spontaneously because of the infarction of the fat. And then a small to moderate size hernias without any peritoneal sac are not inherently dangerous. And then surgery should usually just be offered to patients that are sufficiently symptomatic. So, um there are two approaches, you could do an open and a laparoscopic approach. But uh majority of the surgeons will err on the side of an open approach rather than a laparoscopic approach because this tends to go into the abdominal cavity unnecessarily or even just try to go there to the extraperitoneal space. And then there's a lot of uh risks associated with it while an open surgery might, tends to be a very easy and straightforward one. And then this could just be done by a local anesthesia. So you'll just open the. So usually a vertical or a transverse incision is made over the swelling in the skin. You'll go deep up until you find the subcutaneous tissue and then uh you'll reach the midline raphe or the linear alba, as you can see, like I said, it looks like a mushroom. So the the defect is actually a smaller one underneath the swelling. And then because you can't reduce uh this swell, uh this content, you usually need to make uh an uh last an incision at three and nine o'clock to make that defect wider and roomy enough. So that the content might actually return after you've done um the returning or at least the intra intraabdominal content is returned. You will have to do a figure eight stitch uh using a nonabsorbable su and then skin is closed layer by layer. All right. This is another picture as it, as I've told you, this is an extraperitoneal approach of uh an abdominal uh a laparoscopic approach where a mesh might be used. So sometimes if the defect is large enough and it's involving bowel, uh laparoscopic uh surgeries might uh be better. All right, next up. And actually, I would deem this the most important one is uh incisional hernias. Now, you will encounter this in uh your career as a medical student as a general practitioner or even as a surgeon. Um So let's try to discuss the point canal incisional hernias are a little bit different from every type of hernias that we've discussed so far because there, there's no inherent defect or weakness in the abdominal layer, you're actually creating it yourself. So this will arise through a defect in the muscular facial layers, which was created by the surgeon in the region of the postoperative scar. So, this may occur or they may appear anywhere in the abdominal site where the surgery was taken or the surgery or the incision for the surgery was taken or was done. Now, um, the incidence is quite high during uh laparotomy incisions. It could reach as high as 50%. But uh laparoscopic port site incisions uh can have as low as low as 1% and it could go as high as uh 5%. Now, the average, we usually just say 2%. And I think a question was raised about this uh last time. Uh If we could do uh prophylactic uh mesh pair for a port site in incisions, I think there was a confusion or a mess up uh on the understanding cause sometimes a port site incision hernias are known as a parasal hernias mistakenly are actually labeled for that. But I uh I would like to make that correction. Now, a port site, uh uh incisional hernias are very rare as small as 2% and even as low as 1%. So, doing a prophylactic uh mesh repair here would not be uh cost-effective, but we will see later on, it would be cost-effective if you're doing it in a parasal hernias. All right. So an incisional hernia usually starts as a disruption in the muscular uh facial layers of a wound, early uh postoperative period. However, this is usually not uh recognized, especially if the overlying skin is healing very well. Now, the classic sign of wound disruption is a serosanguinous discharge. Usually, this might also be just a normal uh discharge which is usually overlooked uh during uh the postoperative period. Now, uh there are multiple risk factors associated with incisional hernias and they usually are uh classified or uh grouped into threefold. So, there is a patient related factors which would include increased age, obesity. Uh The subcutaneous tissue depth at incision that is the more obese or the more uh deep uh or at least the more thicker the subcutaneous tissue is the more likely that the patient might have an incision or hernia. Uh previous laparotomy, previous in institutional hernias, preoperative chemotherapy and liver disease are patient related factors. Indication for surgery, usually an emergency laparotomy is one of the most common uh factors that you you encounter in your daily life. So you'll see a very obese uh uh mother which was just delivered maybe about uh three months back and it was an emergency cesarean section that was done and then she would come to you with a swelling that started somewhere around the second week post-operatively, but she didn't mind it because it was very small. But increasingly as time goes by, the swelling has increased and then she might come to you worried. Surgery for obesity and surgery for uh abdominal aortic aneurysm are also another uh surgery uh indications for surgery as listed for risk factors. Surgical factors will be midline incision, surgical site infections and intraoperative blood transfusions. All right. These hernias commonly appear, as I said as a localized swelling involving a small portion of the scar, but it may also be a diffuse bulging throughout the whole length of the incision. Now, there may be several discrete hernias along the length of the incision and then maybe unsuspected defect also might arise. So it will, er, as uh I would go into later on into the clinical approach for you to do either a laparoscopic approach so that you could see all the defect or to do a ct at this point because you might uh need to see the number of defects or if there are any unsuspected defects that you might uh have overlooked. Now, the skin overlying the large hernias, like I said, might become uh previously like the they might become atrophic. And you know, sometimes you might even see the peristalsis occurring underneath the skin, vascular damage might ca vascular damage to the skin might cause uh dermatitis and sometimes attacks of partial intestinal obstruction might arise. And then you might see uh some uh mm the patient will push in the bowel and then it, it, they, they will complain of some uh barb arrhythmia or some uh sounds that they will hear after reducing the content. All right. So this is a picture of uh an incisional hernia. So this you could see the scar, a midline scar that was previously done. And then you see some irregular bulging that is involving the entire abdomen around here. So, uh this is a laparoscopic view of that same uh patient and you can see there are multiple defects. So the contents have been reduced here. So there are multiple defects as you can see 12. And I believe this is the third one that might be an adhesion. Yeah. So there are multiple defects usually and that's usually the case. All right. So let's come to treatment now, as symptomatic incisional hernias may not require treatment at all. The reason for that is sometimes especially the risk factors of that individual might uh predispose them to having a recurrence even after correcting that hernia. So what we would advise is especially uh if the patient is very obese, if the patient uh is debilitated, old age, like a chronic smoker, we will just er on not operating, especially if it's asymptomatic and we might advise the patient to wear uh a binder or a belt to prevent the hernia from increasing in size. Now, uh the principles of surgery tend to change a little bit uh in incisional hernias, uh they're usually straightforward. So you can approach them in an open approach or a laparoscopic one, a laparoscopic one would be much more uh advisable at this point if it's available. But if it's not open, uh hernia, repairs has actually been successful in my experience. Now, a number of principles do apply here, irrespective of the technique that is the repair cover should actually, the repair should actually cover the whole length of the previous incision. Approximation of the musculofascial layer should occur with minimal tension and a prosthetic mesh is very, very necessary. This is this is because it's going to reduce uh recurrence. Now, a mesh might be contraindicated if there is a contaminated field, that is if the bowel injury or during uh adhesion dissection or if there was gangrene at this point, you really don't need to do uh a prosthetic mesh use. Maybe you need to um appoint the patient for an elective reinforcement surgery later on. But if it's just a clean contaminated field, you could just approach it and then do the retro vascular. You can use the retro vascular space. So what you would do is uh I think I could show you here. What you would do is you would open the whole entire scar, previous scar. And then this is the posterior uh fascia that posterior fascia can be closed. As you can see here, it's cleanly closed here and then a mesh is inserted into that retro muscular space and then the anterior uh fascia is closed and then the skin is closed later on, this will give you the atmos um reinforcement and reduce the recurrence. All right. So what happens if the incisional hernia is very large? Now, uh what is very large? The the term large is very subjective. So the cutoff point is 25% by volume. This is very easily cal using city images. Now, uh the reason we classify it like this is because it's very difficult uh for management. So if you approach a very large incisional hernia or whatever, the hernia, if it's very large and it contains more than 25% of the volume. If you approach it just straightforward and you try to replace the contents of the sac back into the abdomen, what it would cause is either two things, either it will not fit back in or even if it did, it will cause a very high tension. And now that high tension will have uh three unwanted uh outcomes. One is it will cause visceral compression. So you might actually have a gangrenous bowel after replacing it. Two is it will have pulmonary compli complications because the impaired diaphragmatic there is going to be an impaired diaphragmatic movement. The third is the tight abdominal closure might actually lead to a wound breakdown and a failure of that repair. So, because of this reason, um a technique has been developed where you will have to acclimatize the bowel, the um abdominal cavity by creating pneumoperitoneum. So the patient will be called in on a two weekly or fortnightly basis and then uh a certain pressure of uh uh a gas with a certain pressure. So usually we use carbon dioxide to create pneumoperitoneum. And then the patient is followed like that by uh consecutively increasing that intra-abdominal pressure. So that at least the patient could acclimatize uh to that uh uh intra-abdominal pressure. So the pa the surgery is done after about eight weeks. Usually while the after the patient uh after the surgeon deems that the patient can actually withstand that pressure once the uh content is replaced back in. So, and then the closure at this point because the content has been very large and the defect has been very large, you could close it without tension. So there is a must that you would need to use uh some type of mesh. And because of these usually the most cases are just referred to specialist centers where patients or surgeons that are specialized in abdominal hernia repairs will handle these kind of cases. So this is a case actually taken from uh BMJ. As you can see, this woman has a scar right around their uh uh her umbilical region. And uh the history goes that uh she had a repair for an umbilical hernia, but then uh she presented to the emergency department with a 24 hour history of abdominal uh intestinal obstruction and this large hernia uh appearing now uh AC T was done. And as you can see, you really don't need to calculate the volume. And when comparing these two things, they look like they're about equal. So somewhere around 40 to 50% of the abdominal cavity was outside. So at this point, a pneumoperitoneum needed to be created. Now, if you've gone, if you go and review the article, they say that they did a straightforward and replace everything and then there was no complications, but it is, it is at this point that you would really need to refer this patient to a specialist or try to do a pneumoperitoneum uh approach and then consecutively try to acclimatize the uh abdomen for very high pressure. But maybe the reason for that could be, the patient came with a very short history. So that is one day usually for a hernia to reach this big, it might be months that the contents were out there. So the intra abdominal pressure might be severely reduced. But because this was an acute case, maybe that's the reason why it hasn't uh brought up. Uh the complications. All right. So that was incisional hernias. Next up is uh spel and hernias. These are the most underdiagnosed and actually the least common of your hernias and the these hernias will uh affect men and women equally. But usually they are, they have a predilection for age, usually are seen in uh elderly. They will arise through a defect in the spel in facia, which is actually the alps of the transversus abdominis muscle. Uh There is a common misconception saying that they will protrude below the aqui line because there's a deficiency of uh posterior sheath there. But studies have actually shown that they always occur above the Eliquis line almost all all the time. Now, young patients, you uh they usually con in young patients, they usually contain only the ex of fat. And then at this point, this is where the confusion will be created, the patient will just complain of very irregular abdominal discomfort, which just comes and goes. And then once you palpate it because of the acetic cats or even reduction on its own, you might not be able to palpate it. And um there are some studies have actually also described uh speech and hernias in infants and it's deemed that it might also be a congenital case. So this is a pictorial view. as you can see, the defect is in the Spela facia, which is just the ais of the transversus abdominis. And then the content will actually just protrude uh and progress uh into the internal oblique uh and then into the space between the external and internal oblique. And it's this, it's here where you'll find the, the swelling. Now, this area deemed with uh uh at least uh labeled number four. This is where we would call the spill hernia belt. And uh this is the acu line. So usually they will occur somewhere around here and actually somewhere around here. This is your spon fascia all here. It's a very rare that you'll see a spon uh hernia somewhere around here. This is a laparoscopic view showing you how the extraperitoneal fat has actually been involved into that uh defect as you can see here. Ok. So the clinical feature is that young patients usually present with intermittent pain due to the pinching of that fat, similar to that of the epigastric hernia a lump may or may not be palpable because of the fatty hernia is actually very small. And then you, this is where the most of the confusion uh happens in diagnosis. Older patients, however, may generally present with a reduce swelling, sometimes even present as far as severe as uh intermittent uh obstructions diagnosis should be suspected because of the location of the symptoms. And usually it's confirmed by AC T. However, sonography is the main stay. Uh And one note here is that if you're going to do uh an sonography, it is, it should be done in an upright uh patient because the, it's usually reducible. The, the, the hernia is usually reducible. And if the patient is lying down, you might not see any defect. Uh and you might not appreciate the, the hernia treatment is surgery and it's uh still the mainstay because of the narrow fibrous neck and it might predispose to strangulation. And then surgery could be approached either in an open or a laparoscopic view in a laparoscopic approach. Sorry. All right. Let's move on uh to the next uh hernia, which is uh lumbar hernia. All right. So lumbar hernias uh will occur through two structures that are just weak by design. And these uh structures or these areas of weakness have been labeled superior and inferior uh um lumbar triangles. So, inferior lumbar triangle is this triangle you see down here and then the superior lumbar triangle is this triangle you see up here. Now, both of them are deemed weak by the uh nature or at least weak by design because they are only covered by a facial. So, uh uh most primary lumbar hernias will occur through this triangle here. Uh That's the inferior lumbar triangle or sometimes known as the triangle of petite. Uh This uh triangle is bounded by uh iliac crest inferiorly medially by the lats muscle Lato and then uh laterally by the uh lateral margin of the external oblique, superior. Uh lumbar triangle is bounded by uh the 12th rib uh superiorly uh medially by the quadratic lumbar muscle and then laterally by the internal oblique muscles. Now, uh primarily like I said, you'll see uh herniation through the triangle of petite or the inferior lumbar triangle here. Uh And usually the most common cases, sometimes uh it comes in exams is a very malnourished uh patient from a low and middle income countries. That's usually the most common case even in the specter. You see, the patient has uh noted that he has actually filaria rashes somewhere around here. If you can note it here, he has filaria rashes. So this patient might have had muscular weakness that has arised due to that filaria infestation and then they might have resulted into this. So there's malnourishment due to chronic illnesses and then that has resulted into this uh into this herniation most commonly in a developed care world. We would see a secondary uh lumbar hernia, that is an incisional lumbar hernia because this area is where we would incise for renal uh surgeries. And that's usually going to be your cases in a developed world. All right, your differential diagnosis, uh usually will include three. That's your lipoma, your cold abscess and pseudo hernias treatment. Now, the natural history of this is that as these hernias will, are bound to just increase in size as time goes on. So bowel will be involved within those uh hernia sacks. So, surgery is eminent. So, if you're not going to do it now, because it's at least not that symptomatic, rest assured that you will do it somewhere uh along the line. So the defect are actually uh wide enough and then you cannot approximate those muscles uh using just sutures. So at this point, uh mesh repair is recommended beca the laparoscopic approach is actually gaining popularity these days. All right. Mm We come to our final um hernia. That is your uh parasal hernias. And these are the ones that are a little bit different and these are the ones I would want to uh reiterate because I've mentioned that before. So parasal hernias are uh much more similar to that of an incisional hernia. The reason is that when a surgeon creates a stoma for colostomy or ileostomy, what we are doing is we're effectively creating a hernia by bringing the bowel out through the abdominal wall. So, and that defect is not reinforced or closed by, it's permanently left open. So this musculofascial weakness with time will bring about herniation of the abdominal uh con constituents. Now, the rate of parasal hernias is over 50%. In some studies, it was as high as 50%. Those studies were actually uh followed for up to 10 years uh for patients with stoma and in those cases, the rate of hernial formation was 100%. So for patients, it's very difficult to manage stoma that is lying adjacent or atop a large hernia. Usually, what you will find is the patients will come to you complaining of a very poorly fitting bags and then the patients will complain of leaking of those bowel contents. And this will bring about a lot of problems on the patient, usually mental and social issues where he cannot uh socialize as much as he needs. And then it has kept him from from at least going out because he's a little bit um worried that it might spill. Usually this is just the cases that you might encounter uh in your uh outpatient cases. So uh the issue comes uh well, ideally, if you're gonna solve paras stomal hernias, what you would do is reanastomosis, what you take it with the bowel that you took out and then remove the stoma altogether. But this is not always possible for one, for instance, say a patient where you had a patient who for who had uh anal cancer. And then you do an abdominal perineal resection where you will con constantly close the anal canal and then you will have a permanent stoma. This patient is bound to actually develop uh parasal hernias as time goes by and you cannot replace the bowel because there's nothing to connect it to. So these situations, there was a conundrum as to what to do. So, uh relocating the stoma was one of the approach that was carried by. And then if um time has revealed that you're just creating another musculofascial weakness and then another uh area for herniation as well. So let's try to see the pictures and then maybe we'll discuss the. So the solutions that has been dis devised uh in the end. So this is the bridge that you've created by creating this toma. But as time goes by the defect will enlarge and then another bowel will just come to it. So this is what it would look like when it's just a little bit small and then it would enlarge as you can see here. Funny enough, it looks like the stomal bag is actually fitting very well on this defect. But usually the patients will uh come to you complaining of ill-fitting bags. All right. So management now, uh various uh open suture, even mesh techniques have been described to repair the parasal hernias, but the failure rates is very high. In some studies, it even grows as high as 80 to 100%. So um the problem is a very eminent one and then it seems that whatever you do the the rate of recurrence is very high. So what we are doing now or at least what is gaining uh popularity is a prophylactic me. So what we would do is a surgeon will actually uh choose a patient profile. So a patient who is obese, a patient with a lot of uh predisposing factors for herniation, a patients with previous hernial surgery. Uh the patient who is a chronic smoker, a patient who is a cancer patient who might do radiation therapy, which might actually weaken the uh abdominal, the wall. So these patients or if they're doing uh any stoma, it is now uh um advised to do a prophylactic mesh. So the that prophylactic mesh is done due to uh in a fashion of a keyhole configuration where uh I I'll show you the picture later on and then this has shown promise. It's showing that uh the rate of herniation has been prevented well enough. But still it's being studied. Uh one of the study that uh reports that is the Melbourne uh report and it, it is showing promise and this is one that uh most surgeons are practicing at this point. So, indications for required repair are strangulation, incarceration and non resolving obstruction indications for elective. It's because of these reasons that sometimes we might not, we might urge on not operating because the rate of the failure rates are very high. So if the peral bulging is just very minor, if there's a poor appliance, uh fit and the patient can actually just manage by doing a little bit of a trick on the stoma bag, then we would advise on that. But these are the ones we cannot bypass. If there's any strangulation, incarceration or non resolving obstruction, then you should go for that repair. So these were the ones I was uh telling you about. So this is the keyhole configuration and this is the chosen uh mesh configuration. The reason for that is that it doesn't cause any kinking of the bowel. Uh still, it's still used, but uh not the favorite one is the sugar pay care configuration. And the reason for that is that it does tend to cause a liquid kinking, which is not just favorite. All right, everyone. So that was all for today. Thank you for your time. At this point. I'll open the stage four Q and A. Hello? Can you hear me? Yes, I can hear you. Can't hear me. Perfect. OK. So let's try to take uh Q and A at this point. Uh Was there any questions that were posted before? Any feedback? Any questions you're all welcome to just leave it at the message box and then I'll see it. Usually if they're not, if there's no questions, it's either it was really good. Or it was really bad. So I'll, I'll decide to believe that it was really good. All right. So, uh if we don't have any more questions, I think I will just terminate uh our meeting for today. Thank you, everyone for attending. Uh, and I think all a while we could just close. Yeah. Thank you so much for enough for um this session. I believe it was a, was an a new one. So, um I, I hope you are willing to share your slides with those. So, yeah. Yeah, definitely, definitely. Both, both the slides, the part one and part two. All right. I'll just drop it in our group and then they could just down. All right. All right. Thank you so much. Thank you, everyone for doing. Thank you, everyone. I think any questions. Yeah. Thank you both for joining. Oh, all right. So um have a good night. Thank you. Good night. You know, she's up.