46) Burst Abdomen & Incisional Hernia скачать в хорошем качестве

46) Burst Abdomen & Incisional Hernia

BURST ABDOMEN ( Abdominal wound dehiscence) :- When an abdominal wound gapes open or disrupts the condition is called burst abodomen is usually seen between the 6th and 9th day after operation. But disruption of the wound occurs earlier in the deeper layers. THE FACTORS WHICH ARE INCRIMINATED TO CAUSE BURST ABDOMEN ARE :- A. Factors relating to the patients:- i. Obesity. ii. Aduanced age iii. Multiparity iv. Malnutrition v. Peritoneal dialysis vi. Jaundice vii. Hypoproteinaemia viii. Anaemia ix. Malignat disease are all important facutors which contribute to the development of burst abdomen and incisional hernia. x. Coughing and vomiting B. Facults of the surgon:- i. Choice of incision ii. The type of operation iii. Method of closure iv. Choice of sauture material v. Drainage through the main abdominal wound often causes burst abdomen Clinical feature:- It is twice as common in men than in women This usually occurs between the 6th and 10th postoerative days. Management:- The abdominal wound should be immediately covered with a sterile towel wrung out of warm saline. A nasogastric tube should be inserted to decompress the stomach intravenous fluid therapy should be started immediately. INCISIONAL HERNIA ( SYN. Ventral Hernia or postoperative hernia ) An incisional hernia is one which occures through an acquired scar in the abdominal wall caused by a previous surgical operation or an accidental trauma. Aetiology :- 1. Defect with patient :- i. Obese individuals with lax muscle. ii. Patients suffering from chronic cough, which may continue in the early postoperative perioed and will lead to incisional hernia. Unduce abdominal distension in the early postoperative period . Malnutrition - patients with severe anaemia hypoproteinaemia or vitiamin c deficiencey may predispose to incisional hernia. 2. Fault during operation - 3. Postoperative cause.- Pathology . (A) .So careful closure of the wound is extremely important to prevent incisional hernia. (b) Wound infection often causes disruption of sutures thus the muscles are separated by weak scar tissue. Clinical features- SYMPTOMS the swelling and the pain. Sometimes attacks of subacute intestinal obstruction may abdominal colic, vomiting constipation and distension of the abdomen, Strangulation, though uncommon, is liable to occur at the neck of a small sac or in a locule of a large hernia Treatment. 1. PREVENTIVE TREATMENT a)If the patient is obese, weight should be reduced by dietting if an elective operation has to be performed. b)If the patient has a tendency of chornic bronchitis it should be treated first. c) Deeper layers must be sutured with due respect. d) All precautions should be adopeted to prevent immediate postoperative wound infection. 2) CONSERVATIVE TREATMENT:- This method cannot be adopted if the hernia is irreducible. After reducing the hernia a belt is fitted with suitable pad so that the hernia does not get an opportunity to come out. 3) OPERATIVE TREATMENT:- This is always indicated in type II cases and irreducible type I case. DIVARICATION OF RECTI :- This condition means that the two recti muscles separate from each other and a good gap cysts between the Iwo recti muscles. causes- (i) Multiple pregnancies (ii) Repetaed middline abdominal operations im which the linea allba may stretch Anatomical Anatomical pathology:- The two recti are inserted to the pubis close to each other, but the origins are quite apart from the anterolateral aspects of the lower ribs. When the recti contract the upper portions tend to move apart from each other moreover contraction of the oblique and transverse abdominal muscles is added to this. So it is nol surprising that the recti can a few inches from each other if the linea alba is weak Clinical features:- During straining, abdominal contents bulge through the gap between the two recti muscles on examination one can easily detect the gap between the two the recti through which fingers can be introduced. LUMBAR HERNIA- There are there types of lumber hernia the first two are primarey lumber hernia which come out through the superior lumbar triangle and the inferior lumbar triangle. The 3rd one is an acquired lumbar hernia and is better called an incisional lumber hernia 1) Superior lumbar hernia 2) inferior lumber hernia 3) incisional lumber hernia Treatment :- Primary lumbar hernia is tratead by herniotomy and repair of the gap herniorrhaphy. OBTURATOR HERNIA- It means hernia occurs through the obturator foramen,traversed by the obturator vessels and nerve.this obturator foramen is wider in females and that is why it is about 6 times more common in women. Treatment:-Abdominal apporach is usually preferred by lower paramedian incision. Femoral approach- a vertical incision is made exctending dawonwards from the inguinal ligament 2 cm medal to the femoral vessels.