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Abdominal Wall Conditions: Treatment Overview

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1. Inguinal Hernia

Types

Conservative Management

• Asymptomatic direct hernias in elderly or high-risk patients: watchful waiting is acceptable (Bailey & Love, p. 1089)
• Surgical trusses are not recommended
• Patient should be counselled to seek early review if hernia enlarges or becomes symptomatic

Surgical Management (Elective)

Open Repair

Laparoscopic Repair

Indications for Emergency Surgery

• Incarcerated hernia (irreducible, obstructed) → urgent reduction or surgery
• Strangulated hernia (ischaemic bowel) → emergency surgery; bowel resection may be needed

Complications of Repair

• Haematoma/seroma
• Wound infection
• Chronic groin pain (ilioinguinal nerve injury)
• Mesh infection/migration
• Recurrence (1–3%)
• Ischaemic orchitis / testicular atrophy (rare)

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2. Umbilical Hernia

Pathophysiology

Paediatric Umbilical Hernia

• Most close spontaneously by age 2–4 years
• Surgical repair indicated if:
  • Persists beyond age 4–5
  • Defect >1.5–2 cm
  • Symptomatic or incarcerated

Adult Umbilical Hernia

• Generally repaired electively due to risk of incarceration (bowel or omentum)
• Small defects (<1 cm): primary suture repair (Mayo's "vest-over-pants" technique)
• Larger defects (>1–2 cm): mesh repair (open or laparoscopic) — lower recurrence rates

Special Circumstances (Bailey & Love, p. 1094)

• Pregnancy-related: often develop postpartum; strong recommendation to avoid surgery during/before pregnancy unless complicated
• Patients advised: weight loss, abdominal muscle exercises; may resolve spontaneously within months
• Rectus divarication (diastasis recti) often co-exists and should be addressed

Complications of Repair

• Recurrence (higher with suture-only repairs in large defects)
• Wound infection
• Mesh-related complications (chronic pain, erosion)

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3. Gastroschisis

Definition

Key Distinguishing Features

Prenatal Management

• Diagnosed on antenatal ultrasound (typically 18–20 weeks)
• Serial ultrasound to monitor bowel and fetal growth
• Delivery at a tertiary centre with neonatal surgical facilities
• Timing: typically 37–38 weeks (or earlier if bowel compromise); caesarean section not mandatory

Postnatal Immediate Care

1. Wrap exposed bowel in warm saline-soaked gauze then cling wrap/bowel bag to prevent heat and fluid loss
2. Nasogastric decompression
3. IV fluid resuscitation (significant third-space losses)
4. IV antibiotics (broad-spectrum)
5. Keep neonate warm; nurse on side to prevent mesenteric tension

Surgical Repair

Primary (Immediate) Closure

• If the abdominal cavity can accommodate bowel without raising intra-abdominal pressure (IAP)
• Performed in the NICU or OR
• Sutureless/umbilical cord closure techniques increasingly used

Staged Closure with Silo

• Used when primary closure would cause abdominal compartment syndrome (IAP >20 mmHg)
• Spring-loaded silo placed at bedside in NICU without anaesthesia
• Bowel gradually reduced over 5–10 days by gravity
• Formal fascia closure once bowel fully reduced

Postoperative Issues

• Prolonged ileus (weeks) — TPN required until gut function returns
• Risk of short bowel syndrome if intestinal atresia/ischaemia present
• Necrotising enterocolitis

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4. Omphalocele (Exomphalos)

Definition

Key Distinguishing Features

Classification

Associated Syndromes

• Beckwith-Wiedemann Syndrome (macroglossia, gigantism, hypoglycaemia)
• Pentalogy of Cantrell (cardiac + diaphragmatic + sternal + pericardial defects + omphalocele)
• OEIS complex (Omphalocele, Exstrophy, Imperforate anus, Spinal defects)
• Chromosomal anomalies (Trisomy 13/18): thorough workup before surgery

Prenatal Management

• Antenatal diagnosis on ultrasound (often earlier than gastroschisis)
• Fetal echocardiography and chromosomal analysis (amniocentesis) essential
• Multidisciplinary counselling

Postnatal Immediate Care

1. Do NOT rupture the sac — it protects the viscera
2. Keep sac moist and protected
3. IV access, nasogastric tube, IV fluids
4. Thorough assessment for associated anomalies (echo, renal US, genetics)
5. Treat hypoglycaemia (Beckwith-Wiedemann)

Surgical Repair

Small Omphalocele — Primary Repair

• Sac excised
• Viscera reduced and fascia primarily closed
• Performed once neonate is stabilised

Giant Omphalocele — Staged Approaches

Prognosis

• Gastroschisis: generally good survival (>90%) if no major atresia; bowel function recovery may take weeks
• Omphalocele: prognosis driven by associated anomalies — isolated omphalocele has good outcomes; Trisomy 13/18 carries poor prognosis

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Quick Comparison: Gastroschisis vs. Omphalocele

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Inguinal Hernia: Male vs. Female Differences

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1. Anatomical Basis of the Difference

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2. Type of Hernia

Clinical pearl: In a female presenting with a groin lump, femoral hernia must be actively excluded before assuming it is inguinal — femoral hernias are proportionally far more common in women and carry a higher strangulation risk.

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3. Surgical Approach Differences

In Males

• The spermatic cord must be carefully identified and preserved during repair
• Structures at risk: vas deferens, testicular vessels → injury can cause ischaemic orchitis or testicular atrophy
• Mesh repair (Lichtenstein or laparoscopic TEP/TAPP) is standard
• The cord is encircled and retracted throughout the dissection

In Females

• The round ligament is present instead of the spermatic cord
• The round ligament can be divided during repair without significant consequence (it has no critical function in adults), which actually simplifies the repair technically
• Division allows a tighter closure of the internal ring
• Mesh repair is still preferred for adults
• The canal of Nuck (female analogue of the processus vaginalis) may persist and form a cyst or hydrocele of the canal of Nuck — this must be addressed at the time of hernia repair

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4. Paediatric Differences

In girls, prolapsed ovaries into the hernia sac require prompt repair to prevent torsion and loss of ovarian function (Bailey & Love, p. 277).

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5. Mesh Considerations

• Mesh use is standard in both sexes for adult repair
• In women of reproductive age: some surgeons prefer laparoscopic repair (TEP/TAPP) to avoid mesh contact with reproductive structures and reduce chronic groin pain
• In males: mesh must not compress the vas deferens (risk of obstruction and infertility) — proper placement is critical
• Young males (especially those desiring future fertility): some advocate non-mesh (pure tissue) repair to avoid any risk to the vas, though this remains debated

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6. Summary Table

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Gastroschisis vs. Omphalocele

Prenatal Ultrasound Comparison

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Side-by-Side Comparison Table

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Embryological Origins

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Similarities

1. Both are congenital abdominal wall defects — viscera herniate outside the body
2. Both are diagnosed prenatally on routine ultrasound (elevated maternal AFP in both)
3. Both require delivery at a tertiary centre with neonatal surgical facilities
4. Vaginal delivery is appropriate for both (caesarean not routinely required)
5. Both require immediate postnatal stabilisation: IV access, nasogastric decompression, IV fluids, IV antibiotics, temperature maintenance
6. Both are ultimately treated surgically — primary closure or staged repair
7. Both may require TPN/PN postoperatively during gut recovery
8. Both involve multidisciplinary care: neonatology, paediatric surgery, NICU nursing

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Management Comparison

Immediate Postnatal Care

Surgical Repair

Postoperative

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Prognosis

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Memory Aid

Gastroschisis = Gut out, Guts exposed, Good chromosomes (rarely associated), to the Right, No sac

Omphalocele = Ombilical, Owned by a sac, Often has other anomalies, On the midline

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