2012-04-28T18:46:19Z

AwniShahait: /* Open adrenalectomy */

{{Interventions infobox |
Name = {{PAGENAME}} |
Image = |
Caption = |
ICD10 = |
ICD9 = 07.2 |
ICD9_mult = {{ICD9proc|07.3}} |
MeshID = D000315 |
OtherCodes = |
}}
{{SI}}
{{EH}}

'''Adrenalectomy''' is the surgical removal of one or both ([[bilateral]] adrenalectomy) [[adrenal glands]]. It is usually advised for patients with tumors of the adrenal glands. The procedure can be performed using an open incision or laparoscopic technique.

==Choice of procedure==
Adrenalectomy may be preformed via open or laparoscopic technique. In either approach, the gland may be approached anteriorly, laterally or posteriorly via retroperitoneum. Laparoscopic adrenalectomy has rapidly become the standard procedure of choice for excision of most benign-appearing adrenal lesions less than 6 cm in diameter, but its role in management of adrenocortical cancers is controversial. Open technique is the safest option when dealing with suspected or known adrenocortical cancer and malignant pheochromocytoma.

==Open adrenalectomy==
Of the four approaches to open adrenalectomy (transabdominal, flank, posterior retroperitoneal and thoracoabdominal approaches), the anterior transabdominal approach is the preferred method for any tumors that are too large to be removed laparoscopically and for all invasive adrenal malignancies. The incision most commonly used is an extended unilateral or bilateral subcostal incision, though a midline incision is also an option. The extended subcostal incision yields exposure of both adrenal glands, as well as the rest of the peritoneal cavity. If necessary, it may be extended superiorly in the midline to the xiphoid to provide better upper abdominal exposure for full mobilization of the liver and access to the hepatic veins and the vena cava. The exposure obtained with this incision is sufficient for all but the most extensive adrenal malignancies. If the tumor involves the vena cava, the incision may be extended into a median sternotomy to provide access to the superior vena cava and the heart. The classic thoracoabdominal incision, which extends from the abdomen up through the seventh or eighth intercostal space and through the diaphragm, provides excellent exposure but is associated with increased incision-related morbidity and is rarely used.

Much of the exposure and dissection is the same as in a laparoscopic adrenalectomy; however, because open adrenalectomy is often employed for removal of particularly large tumors, some additional maneuvers may be necessary to achieve adequate exposure and vascular control. For example, it may be helpful to elevate the flank with a roll or a bean-bag mattress and then flex the operating table to open up the space between the costal margin and the iliac crest. Once the abdomen is entered, exploration is carried out for the presence of metastatic disease.
Exposure of the adrenal on the right side is achieved by dividing the right triangular ligament of the liver, as in the laparoscopic approach. The hepatic flexure of the colon is also reflected inferiorly. With large tumors, a Kocher maneuver should be performed to afford better exposure of the vena cava and the renal vessels. The remainder of the dissection proceeds in much the same manner as in a laparoscopic right adrenalectomy. For suspected adrenal malignancies, a wide resection should be carried out, with removal of periadrenal fat and lymphatic tissue and any suspicious lymph nodes. For tumors that appear to involve the vena cava, vascular control of both the IVC proximal and distal to the tumor and the renal veins should be achieved before the lesion is removed.

Open left adrenalectomy entails mobilization of the splenic flexure of the colon and division of the splenorenal ligament. The spleen, the tail of pancreas, and the stomach are reflected medially en bloc to expose the left kidney and the left adrenal. The left adrenal vein is ligated with clips or silk ties near its junction with the renal vein. The remainder of the dissection proceeds as in a laparoscopic left adrenalectomy. For left-side primary adrenal malignancies, periaortic lymphatic vessels and lymph nodes should be removed along with the specimen. If a large left-side tumor is invading adjacent structures, removal may require en bloc resection of the spleen, the distal pancreas, and the kidney.

==Laparoscopic adrenalectomy==
When compared with open adrenalectomy, laparoscopic adrenalectomy has been shown to result in decreased requirement for postoperative pain medication, shorter postoperative ileus, more cosmetically acceptable scars, faster rehabilitation, and lower hospital costs. Laparoscopic adrenalectomy is most suitable for small adrenal masses in an otherwise normal gland. It is the procedure of choice for patients with aldosteronomas, small cortisol-producing adenomas, and small hereditary pheochromocytomas. Expertise in open adrenalectomy is absolutely necessary for the laparoscopic surgeon to convert to an open procedure and to rectify any intraoperative laparoscopic complications promptly. Adrenalectomy for a nonfamilial pheochromocytoma requires exploration of the entire abdomen, best conducted by direct palpation and visualization. Similarly, excision of large malignant tumors with potential invasion of nearby structures can be safely accomplished only by open adrenalectomy.

Laparoscopic adrenalectomy is performed with the patient in the lateral decubitus position with the table flexed at the space between the costal margin and the anterior superior iliac spine. The patient's arm is suspended, and care is taken to prevent compression of the shoulder facing downward. The surgeon and the assistant stand at the patient's back and front, respectively. Monitors, the camera apparatus, the videocassette recorder, and insufflation equipment are then connected. An insufflator is placed within the peritoneal cavity either under direct vision or with the Veress needle in the subcostal position, and the abdomen is insufflated with carbon dioxide gas. Under videoscopic monitoring, the surgeon places the first three intraperitoneal instrument ports equidistantly in a transverse line from the lateral edge of the rectus sheath to the midaxillary line between the costal margin and the iliac crest. The distance between each port should be 5 cm or more. Large 11- or 12-mm ports are used to accommodate camera, retractors, or the Harmonic scalpel. The peritoneal cavity is examined. A fan retractor may be placed through a medial port to retract the viscera medially, anteriorly, and superiorly. Operating instruments, grasping forceps, dissecting forceps, and an irrigation/suction apparatus are alternately placed within the abdomen through the lateral port.

In a laparoscopic right adrenalectomy, a fourth port is placed at the posterior axillary line into the retroperitoneum under direct vision. The right lobe of the liver is mobilized off the retroperitoneum up to the diaphragm and is retracted anteriorly and medially with a retractor. The adrenal gland is identified posterolateral to the inferior vena cava and superior to the kidney. The right adrenal is dissected from the superior pole of the kidney and the inferior vena cava. The right adrenal vein is identified coming off the vena cava and is doubly clipped and ligated. A second, smaller right adrenal vein is often identified superior to the main vein. Soft tissue attachments are divided, and the adrenal is placed in an endoscopic retrieval bag, which is extracted through one of the ports. The adrenal bed is checked for hemostasis, and the retractor, instruments, and videoscope are withdrawn. The operation concludes with closure of the fascial and skin defects.

Left adrenalectomy is performed with opposite patient position and port placement. The spleen is mobilized carefully and is reflected medially. The surgeon must not mobilize the kidney posteriorly because this maneuver will cause the kidney and adrenal gland to fall medially. This situation makes dissection of the adrenal gland extremely difficult. The spleen, the tail of the pancreas, and the stomach may be retracted anteriorly and superiorly with a fan retractor. The splenic flexure of the colon is then mobilized, to allow the left colon to fall inferiorly and anteriorly, away from the retroperitoneum. A fourth port may then be safely placed in the posterior axillary line. The rest of the procedure is performed similarly to a laparoscopic right adrenalectomy.

==Complications==

==External links==
* [http://www.surgeryencyclopedia.com/A-Ce/Adrenalectomy.html Surgery Encyclopedia: Adrenalectomy]

{{Endocrine system intervention}}
[[Category:Endocrine system]]
[[Category:Surgical procedures]]
[[Category:Endocrinology]]
{{SIB}}
[[pl:Adrenalektomia]]

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Adrenalectomy

2012-04-28T18:40:15Z

AwniShahait: /* Laparoscopic adrenalectomy */

Adrenalectomy

2012-04-28T18:28:34Z

AwniShahait: /* Laparoscopic adrenalectomy */

AwniShahait:

Traumatic abdominal wall hernia

2012-04-14T18:04:00Z

AwniShahait: /* Imaging */

__NOTOC__
{{SI}}

{{CMG}}; '''Associate Editor-in-Chief:''' [[User:AwniShahait|Awni D. Shahait, M.D.]], The University of Jordan

'''''Synonyms and keywords:''''' TAWH

==Overview==
Traumatic Abdominal Wall Hernia (TAWH) represents an infrequent form of hernia and constitutes 1% of hernia cases.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref>

==Historical Perspective==
The first case was reported by Selby in 1906.

==Epidemiology and Demographics==
There have been 100 cases reported worldwide. The frequency of cases has increased in the last two decades.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref>

==Classification==
Traumatic abdominal wall hernia is generally classified into three types <ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>
#A small abdominal wall defect caused by low-energy trauma with small instruments (e.g. bicycle handlebar)
#A larger abdominal wall defect caused by high-energy transfer such as motor vehicle accident or a fall from a height
#Iintra-abdominal herniation of bowel with deceleration injures (rare)

==Pathophysiology==
TAWH is defined as herniation of viscera occurring after a force is applied to the abdomen in a patient without preexisting abdominal hernia, resulting in disruption of muscles and fascia while maintaining skin continuity. <ref name="pmid16035382">{{cite journal |author=Hardcastle TC, Du Toit DF, Malherbe C, ''et al.'' |title=Traumatic abdominal wall hernia--four cases and a review of the literature |journal=S Afr J Surg |volume=43 |issue=2 |pages=41–3 |year=2005 |month=May |pmid=16035382 |doi= |url=}}</ref> The mechanism of TAWH is thought to be caused by shear stress associated with acute elevation of intra-abdominal pressure. The shear stress is transferred to the peritoneum, fascia and muscle fibers which is then followed by tissue rupture. These injuries are mostly located below the umbilicus due to weaker musculature in that region since the rectus sheath is present only above the arcuate line<ref name="pmid8331706">{{cite journal |author=Gill IS, Toursarkissian B, Johnson SB, Kearney PA |title=Traumatic ventral abdominal hernia associated with small bowel gangrene: case report |journal=J Trauma |volume=35 |issue=1 |pages=145–7 |year=1993 |month=July |pmid=8331706 |doi= |url=}}</ref>. The hernia may occur at a site fremote from the initial site of trauma.<ref name="pmid8970567">{{cite journal |author=Ganchi PA, Orgill DP |title=Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature |journal=J Trauma |volume=41 |issue=6 |pages=1064–6 |year=1996 |month=December |pmid=8970567 |doi= |url=}}</ref> When traumatic insult to the abdominal wall is mainly due to shearing stresses or tensile forces, intra-abdominal injuries are extremely uncommon.<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>

==Diagnosis==
The criteria for diagnosing TAWH were suggested by McWhorten in 1939, and they are<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>:
#Immediate occurrence following blunt trauma
#Severe pain at the site of the injury
#Patient presents within the first 24 hours
#No previous hernia.

Later, these criteria were modified to include:
#Intact Skin over the hernia and
#No evidence of hernial sac during surgery

===Symptoms===
The majority of these patients present immediately following the trauma, and 26% present later.<ref name="pmid14735329">{{cite journal |author=Kumar A, Hazrah P, Bal S, Seth A, Parshad R |title=Traumatic abdominal wall hernia: a reappraisal |journal=Hernia |volume=8 |issue=3 |pages=277–80 |year=2004 |month=August |pmid=14735329 |doi=10.1007/s10029-003-0203-4 |url=}}</ref>

===Physical Examination===
The classical signs of hernia (i.e., cough impulse and reducibility) are present in only 50% of patients, thus it can be confused with a hematoma. An interesting feature recorded in such a situation is the tendency of such hernias to increase in size over a short period of time.<ref name="pmid3385839">{{cite journal |author=Al-Qasabi QO, Tandon RC |title=Traumatic hernia of the abdominal wall |journal=J Trauma |volume=28 |issue=6 |pages=875–6 |year=1988 |month=June |pmid=3385839 |doi= |url=}}</ref> Bowel sounds can occasionally be heard over such a swelling.

===Imaging===
[[Image: TAWH.jpg|frame|Computed Tomography (CT) scan showing the disruption in the abdominal wall muscles and fascia with herniation of small bowel loops through it.]]
Ultrasound of the abdominal wall is still widely used because of its availability and relatively low cost. For the first evaluation in the emergency room, ultrasound is easily accessible and can be helpful in establishing the primary diagnoses.<ref name="pmid12090580">{{cite journal |author=Losanoff JE, Richman BW, Jones JW |title=Handlebar hernia: ultrasonography-aided diagnosis |journal=Hernia |volume=6 |issue=1 |pages=36–8 |year=2002 |month=March |pmid=12090580 |doi= |url=}}</ref> However, the sensitivity and specificity of the CT scan is much higher and also enables better imaging of the abdominal wall and the intra-abdominal organs which is of interest in the abdominal trauma patient. At present, CT scan is the standard for diagnosing of any form of abdominal wall hernia since the relationship between the different muscle layers and surrounding structure is better visualized.<ref name="pmid12101537">{{cite journal |author=Hickey NA, Ryan MF, Hamilton PA, Bloom C, Murphy JP, Brenneman F |title=Computed tomography of traumatic abdominal wall hernia and associated deceleration injuries |journal=Can Assoc Radiol J |volume=53 |issue=3 |pages=153–9 |year=2002 |month=June |pmid=12101537 |doi= |url=}}</ref>

==Treatment==
Surgical intervention remains the mainstay of management in these patients<ref name="pmid8970567">{{cite journal |author=Ganchi PA, Orgill DP |title=Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature |journal=J Trauma |volume=41 |issue=6 |pages=1064–6 |year=1996 |month=December |pmid=8970567 |doi= |url=}}</ref>, although conservative management has been reported in the literature.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref> There is controversy as to whether to operate immediately or later. The majority of surgeons prefer to operate immediately, and some after a period of conservative management. The timing of surgery depends on the following considerations:
*Surgeon preference
*The timing of presentation
*Comorbidities and fitness for surgery
*The presence of complications
*The hemodynamic status and severity of associated injuries

Surgery is necessary to avoid complications, such as incarceration and strangulation of bowels.<ref name="pmid14735329">{{cite journal |author=Kumar A, Hazrah P, Bal S, Seth A, Parshad R |title=Traumatic abdominal wall hernia: a reappraisal |journal=Hernia |volume=8 |issue=3 |pages=277–80 |year=2004 |month=August |pmid=14735329 |doi=10.1007/s10029-003-0203-4 |url=}}</ref>

Despite the trend to use the laparoscopic approach in treatment of incisional hernias, it infrequently practiced in cases of TAWH.<ref name="pmid12500842">{{cite journal |author=Munshi IA, Ravi SP, Earle DB |title=Laparoscopic repair of blunt traumatic anterior abdominal wall hernia |journal=JSLS |volume=6 |issue=4 |pages=385–8 |year=2002 |pmid=12500842 |pmc=3043450 |doi= |url=}}</ref> Open surgery was selected in most of the reported cases in the literature. Debates exist on whether to use a midline incision or an incision over the hernia. In the majority, midline incision was chosen in acute cases, to rule out associated intra-abdominal injury which occurs in about 30 % to 44% of patients in high energy trauma.<ref name="pmid15227747">{{cite journal |author=Singh R, Kaushik R, Attri AK |title=Traumatic abdominal wall hernia |journal=Yonsei Med. J. |volume=45 |issue=3 |pages=552–4 |year=2004 |month=June |pmid=15227747 |doi= |url=}}</ref> While in low energy induced TAWH, local exploration through an incision over the hernia is preferred.<ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>

The main goal of surgery is reconstruct the disruption of the abdominal wall, which can be achieved either by primary closure or by applying a mesh. It depends on the size and site of hernia, associated intra-abdominal injury and timing of intervention.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref> In TAWH induced by low energy, a primary repair, by approximation of the defect using non-absorbable sutures, was the first choice, because in these cases the soft tissue damage and defect size is minimal.<ref name="pmid15365743">{{cite journal |author=Iinuma Y, Yamazaki Y, Hirose Y, ''et al.'' |title=A case of a traumatic abdominal wall hernia that could not be identified until exploratory laparoscopy was performed |journal=Pediatr. Surg. Int. |volume=21 |issue=1 |pages=54–7 |year=2005 |month=January |pmid=15365743 |doi=10.1007/s00383-004-1264-x |url=}}</ref> On the other hand, in high energy TAWH, the defect size is usually larger and tissue loss is greater, which can’t be repaired primarily. So mesh is preferred, with additional benefit by decreasing the recurrence rate. But not to forget the increased risk of infections in these circumstances.<ref name="pmid12575786">{{cite journal |author=Lane CT, Cohen AJ, Cinat ME |title=Management of traumatic abdominal wall hernia |journal=Am Surg |volume=69 |issue=1 |pages=73–6 |year=2003 |month=January |pmid=12575786 |doi= |url=}}</ref>

==References==
{{Reflist|2}}

[[Category:Surgery]]

{{WH}}
{{WS}}

Hernia

2012-04-14T17:54:38Z

AwniShahait: /* Other types of hernia */

{{Infobox_Disease
| Name = Hernia
| Image = Hernia de Morgani.JPG
| Caption = Frontal [[chest X-ray]] showing a [[hernia of Morgagni]]
| DiseasesDB =
| ICD10 = K40-K46
| ICD9 = {{ICD9|550}}-{{ICD9|553}}
| ICDO =
| OMIM =
| MedlinePlus = 000960
| MeshID =
}}
{{Hernia}}
'''For the WikiPatient page for this topic, click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}} '''Associate Editor-In-Chief:''' [[User: Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org]

{{EH}}

==Overview==

A '''hernia''' is a [[wiktionary:protrusion|protrusion]] of a [[Biological tissue|tissue]], structure, or part of an organ through the muscular tissue or the [[biological membrane|membrane]] by which it is normally contained. The hernia has 3 parts: the ''orifice'' through which it herniates, the ''hernial sac'', and its ''contents''. The contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. a Hernia has a potential risk of having its blood supply cut off (becoming strangulated), and the contents may become necrotic due to the lack of O2 supply.

A hernia may be likened to a failure in the sidewall of a pneumatic tire. The tire's inner tube behaves like the organ and the side wall like the body cavity wall providing the restraint. A weakness in the sidewall allows a bulge to develop, which can become a split, allowing the inner tube to protrude, and leading to the eventual failure of the tire.

==Pathophysiology==
By far most hernias develop in the [[abdomen]], when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which [[adipose tissue]], or abdominal organs covered with [[peritoneum]], may protrude. Another common hernia involves the [[intervertebral disc]], and causes [[back pain]] or [[sciatica]].

Hernias may present either with pain at the site, a visible or palpable lump, or in some cases by more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction due to [[wiktionary:ischemia|ischemia]]. Fatty tissue usually enters a hernia first, but it may be followed by or accompanied by an organ.

Most of the time, hernias develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or weakened.
* Weakening of containing membranes or muscles is usually ''congenital'' (which explains part of the tendency of hernias to run in families), and increases with ''age'' (for example, degeneration of the [[annulus fibrosus disci intervertebralis|annulus fibrosus]] of the [[intervertebral disc]]), but it may be on the basis of other ''illnesses'', such as [[Ehlers-Danlos syndrome]] or [[Marfan syndrome]], ''stretching'' of muscles during pregnancy, losing weight in obese people, etc., or because of ''scars'' from previous surgery.
* Many conditions chronically increase intra-abdominal pressure, (pregnancy, [[ascites]], [[COPD]], [[dyschezia]], [[benign prostatic hypertrophy]]) and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to herniate through narrowed portions of the cranial cavity or through the [[foramen magnum]]. Increased pressure on the intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation.

==Epidemiology==
Between 1995 and 2005, 16,742 Americans died from hernias.<ref name=wirednews>Title {{cite news
| last = Singel
| first = Ryan
| title = One Million Ways To Die
| publisher = Wired News
| date = 2006-09-11
| url = http://www.wired.com/news/technology/0,71743-0.html?tw=wn_index_3
| accessdate = 2006-11-06 }}</ref> The mortality rate varies according to the type of the hernia and whether it is strangulated or not.

==Types and classifications ==
Hernias can be classified according to their anatomical location:

Examples include:
* '''Abdominal hernias'''.
* '''Diaphragmatic hernias and [[hiatal hernia]]s (for example, paraesophageal hernia of the stomach).'''
* '''Pelvic hernias, for example, obturator hernia.'''
* '''Hernias of the nucleus pulposus of the intervertebral discs.'''
* '''Intracranial hernias.'''

Each of the above hernias may be characterised by several aspects:
*'''Congenital or acquired''': congenital hernias occur prenatally or in the first year(s) of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistentiae (Lat. place of least resistance) that is congenital, but only becomes symptomatic later on in life, when degeneration and increased stress (for example, increased abdominal pressure from coughing in [[COPD]]) provoke the hernia.
*'''Complete or incomplete''': for example, the stomach may partially herniate into the chest, or completely.
* '''Internal or external''': external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).
*'''Intraparietal hernia''': hernia that does not reach all the way to the [[subcutis]], but only to the musculoaponeurotic layer. An example is a [[Spigelian hernia]]. Intraparietal hernias may produces less obvious bulging, and may be less easily detected on clinical examination.
*'''Bilateral''': in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.
*'''Irreducible''' (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation.

If irreducible, hernias can develop several complications (hence, they can be '''complicated or uncomplicated'''):
*'''Strangulation''': pressure on the hernial contents may compromise blood supply (especially veins, with their low pressure, are sensitive, and venous congestion often results) and cause ischemia, and later [[necrosis]] and [[gangrene]], which may become fatal.
*'''Obstruction''': for example, when a part of the bowel herniates, bowel contents can no longer pass the obstruction. This results in cramps, and later on vomiting, [[ileus]], absence of [[flatus]] and absence of defecation. These signs mandate urgent surgery.
*Another complication arises when the herniated organ itself, or surrounding organs start '''dysfunctioning''' (for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causing [[sciatic nerve]] pain, etc.)

==Treatment==
It is generally advisable to repair hernias in a timely fashion, in order to prevent complications such as organ dysfunction, [[gangrene]], and [[multiple organ dysfunction syndrome]]. Most abdominal hernias can be surgically repaired, and recovery rarely requires long-term changes in lifestyle. Uncomplicated hernias are principally repaired by pushing back, or "reducing", the herniated tissue, and then mending the weakness in muscle tissue (an operation called [[herniorrhaphy]]). If complications have occurred, the surgeon will check the viability of the herniated organ, and resect it if necessary. Modern muscle reinforcement techniques involve synthetic materials (a mesh prosthesis) that avoid over-stretching of already weakened tissue (as in older, but still useful methods). The mesh is placed over the defect, and sometimes staples are used to keep the mesh in place. Increasingly, some repairs are performed through [[laparoscopy|laparoscopes]].

Many patients are managed through surgical daycare centers, and are able to return to work within a week or two, while heavy activities are prohibited for a longer period. Surgical complications have been estimated to be up to 10%, but most of them can be easily addressed. They include surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence.

Generally, the use of external devices to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.), is not advised. Exceptions are uncomplicated [[incisional hernia]]s that arise shortly after the operation (should only be operated after a few months), or inoperable patients.

It is essential that the hernia not be further irritated by carrying out strenuous labour.

==Individual hernias==
A [[Athletic pubalgia|sportman's hernia]] is a [[syndrome]] characterized by chronic [[groin]] [[Pain and nociception|pain]] in athletes and a dilated [[Superficial inguinal ring|superficial ring]] of the inguinal canal, although a true hernia is not present.

===Inguinal hernia===
:''Main article: [[inguinal hernia]].''

[[Image:Inguinalhernia.gif|left|frame|Diagram of an [[indirect inguinal hernia|indirect]], [[scrotum|scrotal]] [[inguinal hernia]] ( [[Anatomical position|median]] view from the left).]]
By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. For a thorough understanding of inguinal hernias, much insight is needed in the anatomy of the [[inguinal canal]]. Inguinal hernias are further divided into the more common [[indirect inguinal hernia]] (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the [[direct inguinal hernia]] type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are more common in men than women while femoral hernias are more common in women.

===Femoral hernia===
:''Main article: [[femoral hernia]].''

Femoral hernias occur just below the [[inguinal ligament]], when abdominal contents pass into the weak area at the posterior wall of the [[femoral canal]]. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and [[inguinal hernia]].

===Umbilical hernia===
:''Main article: [[umbilical hernia]].''

Umbilical hernias are especially common in infants of African descent, and occur more in boys. They involve protrusion of intraabdominal contents through a weakness at the site of passage of the [[umbilical cord]] through the [[abdominal wall]]. These hernias often resolve spontaneously.
Umbilical hernias in adults are largely acquired, and are more frequent in [[obese]] or [[pregnant]] women. Abnormal decussation of fibers at the [[linea alba]] may contribute.

===Incisional hernia===
:''Main article: [[incisional hernia]].''

An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median [[laparotomy]] incisions in the [[linea alba]], they are termed [[ventral hernia]]s. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue.

===Diaphragmatic hernia===
:''Main article: [[diaphragmatic hernia]]
[[Image:Hiatalhernia.gif|left|frame|Diagram of a [[hiatus hernia]] ([[Anatomical position|coronal section]], viewed from the front).]]
Higher in the abdomen, an (internal) "diaphragmatic hernia" results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.

A [[hiatus hernia]] is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach ([[Diaphragm (anatomy)|esophageal hiatus]]) serves as a functional "defect", allowing part of the [[stomach]] to (periodically) "herniate" into the chest. Hiatus hernias may be either "''sliding''," in which the [[Esophagus|gastroesophageal junction]] itself slides through the defect into the [[chest]], or non-sliding (also known as ''para-esophageal''), in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised.
[[Image:Hernia de Morgani.JPG|thumb|left|Frontal [[chest X-ray]] showing a [[hernia of Morgagni]].]]
A [[congenital diaphragmatic hernia]] is a distinct problem, occurring in up to 1 in 2000 births, and requiring [[pediatric surgery]]. Intestinal organs may herniate through several parts of the [[diaphragm (anatomy)|diaphragm]], posterolateral (in [[Vincenc Bochdalek|Bochdalek's]] triangle, resulting in ''Bochdalek's hernia''), or anteromedial-retrosternal (in the cleft of [[Dominique Jean Larrey|Larrey]]/[[Giovanni Battista Morgagni|Morgagni's]] [[foramen]], resulting in ''Morgagni-Larrey hernia'', or [[Morgagni's hernia]]).

===Other types of hernia===
Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and [[eponyms]]. The above article deals mostly with "visceral hernias", where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:

* '''[[Brain herniation|Brain hernia]]''': herniation of part of the [[brain]] because of excessive [[intracranial pressure]]. This may be a life-threatening condition, especially if the [[brain stem]] (responsible for some important [[vital signs]]) is involved.
* '''Cooper's hernia''': A femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing immediately beneath the skin.
*[[epigastric hernia]]: hernia through the [[linea alba]] above the [[umbilicus]].
*'''Littre's hernia''': hernia involving a [[Meckel's diverticulum]]. It is named after French anatomist [[Alexis Littre]] (1658-1726).
*[[Lumbar hernia]]: hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains following entities:
1. [[Petit's hernia]] - hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon [[Jean Louis Petit]] (1674-1750).

2. [[Grynfeltt's hernia]] - hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840-1913).
*'''obturator hernia''': hernia through [[obturator canal]].
*'''pantaloon hernia''': a combined direct and indirect hernia, when the hernial sac protrudes on either side of the [[inferior epigastric vessels]].
*[[perineal hernia]]: A perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually, is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.
*'''properitoneal hernia''': rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the [[deep inguinal ring]] to the preperitoneal space.
*'''Richter's hernia''': strangulated hernia involving only one sidewall of the bowel, which can result in bowel perforation through ischaemia without causing [[bowel obstruction]] or any of its warning signs. It is named after German surgeon [[August Gottlieb Richter]] (1742-1812).
*'''sliding hernia''': occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The [[Colon (anatomy)|colon]] and the [[urinary bladder]] are often involved. The term also frequently refers to [[sliding hernias of the stomach]].
* '''sciatic hernia''': this hernia in the [[greater sciatic foramen]] most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause of [[sciatic]] neuralgia.
* [[Spigelian hernia]], also known as [[spontaneous lateral ventral hernia]].
*Velpeau hernia: a hernia in the groin in front of the femoral blood vessels.
* [[spinal disc herniation]], or "herniated nucleus pulposus": a condition where the central weak part of the [[intervertebral disc]] ([[nucleus pulposus]], which helps absorb shocks to our [[Vertebral column|spine]]), herniates through the fibrous band ([[annulus fibrosus disci intervertebralis|annulus fibrosus]]) by which it is normally bound. This usually occurs low in the back at the [[lumbar]] or lumbo-[[sacrum|sacral]] level and can cause back pain which usually radiates well into the thigh or leg. When the sciatic nerve is involved, the symptom complex is called [[sciatica]]. Herniation can occur in the [[cervical]] vertebrae too. A [[nucleoplasty]] is an operation to repair the herniation.
* [[Traumatic abdominal wall hernia]]: herniation of viscera occurring after a force is applied to the abdomen in a patient without preexisting abdominal hernia, resulting in disruption of muscles and fascia while maintaining skin continuity.

== Complications ==
Complications may arise post-operation, including [http://www.blackwell-synergy.com/links/doi/10.1111/j.1469-0691.2004.01014.x/full/ rejection of the mesh] that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localised swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed.

An untreated hernia may complicate by:
* [[Inflammation]]
* [[Reduction (orthopedic surgery)|Irreducibilty]]
* [[Bowel obstruction|Obstruction]]
* [[Strangulating|Strangulation]]
* [[Hydrocele]] of the hernial sac

==References==
* ''Surgical recall'', 2nd edition, by Lorne. H. Blackbourne, published by Lippincott Williams & Wilkins
* ''Sabiston textbook of surgery'', 17th edition, Townsend et.al.(e.d.), Elsevier-Saunders

==External links==
*[http://www.hernia.org/ Hernia Resources]
*[http://www.herniablog.com/ The Hernia Blog]
*[http://www.herniasymptoms.org/ Hernia Symptoms]

*[http://www.wikisurgery.com/index.php?title=Hernia-femoral-adult-Operationscript Hernia femoral adult: Operation Script on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-femoral-adult-daycase-Patientinformation Hernia femoral adult day case: Information for patients on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-inguinal-adult-Operationscript Hernia inguinal adult day case: Operation Script on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-inguinal-TAPP-Operationscript Hernia inguinal TAPP: Operation Script on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-inguinal-adult-daycase-Patientinformation Hernia inguinal adult day case: Information for patients on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-inguinal-child-herniotomy-Operationscript Hernia inguinal child: Operation Script on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-inguinal-child-herniotomy-Patientinformation Hernia inguinal child: Information for patients on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-umbilical-adult-Patientinformation Hernia umbilical adult: Information for patients on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-umbilical-child-Operationscript Hernia umbilical child: Operation Script on Wikisurgery].

*[http://www.wikisurgery.com/index.php?title=Hernia-umbilical-child-Patientinformation Hernia umbilical child: Information for patients on Wikisurgery].

===Pictures===
* [http://hernia-pictures.blogspot.com/ Photos of Hernias]

{{SIB}}
{{Gastroenterology}}

[[Category:Surgery]]
[[Category:Hernias]]

[[ca:Hèrnia]]
[[de:Hernie]]
[[es:Hernia]]
[[fr:Hernie]]
[[ko:탈장]]
[[it:Ernia]]
[[he:בקע]]
[[nl:Hernia]]
[[ja:ヘルニア]]
[[no:Brokk]]
[[nn:brokk]]
[[pl:Przepuklina]]
[[pt:Hérnia]]
[[ru:Грыжа]]
[[sr:Брух]]
[[fi:Tyrä]]
[[sv:Bråck]]
[[tr:Fıtık]]

{{WH}}
{{WS}}

Traumatic abdominal wall hernia

2012-04-14T17:43:50Z

AwniShahait: /* Treatment */

__NOTOC__
{{SI}}

{{CMG}}; '''Associate Editor-in-Chief:''' [[User:AwniShahait|Awni D. Shahait, M.D.]], The University of Jordan

'''''Synonyms and keywords:''''' TAWH

==Overview==
Traumatic Abdominal Wall Hernia (TAWH) represents an infrequent form of hernia and constitutes 1% of hernia cases.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref>

==Historical Perspective==
The first case was reported by Selby in 1906.

==Epidemiology and Demographics==
There have been 100 cases reported worldwide. The frequency of cases has increased in the last two decades.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref>

==Classification==
Traumatic abdominal wall hernia is generally classified into three types <ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>
#A small abdominal wall defect caused by low-energy trauma with small instruments (e.g. bicycle handlebar)
#A larger abdominal wall defect caused by high-energy transfer such as motor vehicle accident or a fall from a height
#Iintra-abdominal herniation of bowel with deceleration injures (rare)

==Pathophysiology==
TAWH is defined as herniation of viscera occurring after a force is applied to the abdomen in a patient without preexisting abdominal hernia, resulting in disruption of muscles and fascia while maintaining skin continuity. <ref name="pmid16035382">{{cite journal |author=Hardcastle TC, Du Toit DF, Malherbe C, ''et al.'' |title=Traumatic abdominal wall hernia--four cases and a review of the literature |journal=S Afr J Surg |volume=43 |issue=2 |pages=41–3 |year=2005 |month=May |pmid=16035382 |doi= |url=}}</ref> The mechanism of TAWH is thought to be caused by shear stress associated with acute elevation of intra-abdominal pressure. The shear stress is transferred to the peritoneum, fascia and muscle fibers which is then followed by tissue rupture. These injuries are mostly located below the umbilicus due to weaker musculature in that region since the rectus sheath is present only above the arcuate line<ref name="pmid8331706">{{cite journal |author=Gill IS, Toursarkissian B, Johnson SB, Kearney PA |title=Traumatic ventral abdominal hernia associated with small bowel gangrene: case report |journal=J Trauma |volume=35 |issue=1 |pages=145–7 |year=1993 |month=July |pmid=8331706 |doi= |url=}}</ref>. The hernia may occur at a site fremote from the initial site of trauma.<ref name="pmid8970567">{{cite journal |author=Ganchi PA, Orgill DP |title=Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature |journal=J Trauma |volume=41 |issue=6 |pages=1064–6 |year=1996 |month=December |pmid=8970567 |doi= |url=}}</ref> When traumatic insult to the abdominal wall is mainly due to shearing stresses or tensile forces, intra-abdominal injuries are extremely uncommon.<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>

==Diagnosis==
The criteria for diagnosing TAWH were suggested by McWhorten in 1939, and they are<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>:
#Immediate occurrence following blunt trauma
#Severe pain at the site of the injury
#Patient presents within the first 24 hours
#No previous hernia.

Later, these criteria were modified to include:
#Intact Skin over the hernia and
#No evidence of hernial sac during surgery

===Symptoms===
The majority of these patients present immediately following the trauma, and 26% present later.<ref name="pmid14735329">{{cite journal |author=Kumar A, Hazrah P, Bal S, Seth A, Parshad R |title=Traumatic abdominal wall hernia: a reappraisal |journal=Hernia |volume=8 |issue=3 |pages=277–80 |year=2004 |month=August |pmid=14735329 |doi=10.1007/s10029-003-0203-4 |url=}}</ref>

===Physical Examination===
The classical signs of hernia (i.e., cough impulse and reducibility) are present in only 50% of patients, thus it can be confused with a hematoma. An interesting feature recorded in such a situation is the tendency of such hernias to increase in size over a short period of time.<ref name="pmid3385839">{{cite journal |author=Al-Qasabi QO, Tandon RC |title=Traumatic hernia of the abdominal wall |journal=J Trauma |volume=28 |issue=6 |pages=875–6 |year=1988 |month=June |pmid=3385839 |doi= |url=}}</ref> Bowel sounds can occasionally be heard over such a swelling.

===Imaging===
Ultrasound of the abdominal wall is still widely used because of its availability and relatively low cost. For the first evaluation in the emergency room, ultrasound is easily accessible and can be helpful in establishing the primary diagnoses.<ref name="pmid12090580">{{cite journal |author=Losanoff JE, Richman BW, Jones JW |title=Handlebar hernia: ultrasonography-aided diagnosis |journal=Hernia |volume=6 |issue=1 |pages=36–8 |year=2002 |month=March |pmid=12090580 |doi= |url=}}</ref> However, the sensitivity and specificity of the CT scan is much higher and also enables better imaging of the abdominal wall and the intra-abdominal organs which is of interest in the abdominal trauma patient. At present, CT scan is the standard for diagnosing of any form of abdominal wall hernia since the relationship between the different muscle layers and surrounding structure is better visualized.<ref name="pmid12101537">{{cite journal |author=Hickey NA, Ryan MF, Hamilton PA, Bloom C, Murphy JP, Brenneman F |title=Computed tomography of traumatic abdominal wall hernia and associated deceleration injuries |journal=Can Assoc Radiol J |volume=53 |issue=3 |pages=153–9 |year=2002 |month=June |pmid=12101537 |doi= |url=}}</ref>

==Treatment==
Surgical intervention remains the mainstay of management in these patients<ref name="pmid8970567">{{cite journal |author=Ganchi PA, Orgill DP |title=Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature |journal=J Trauma |volume=41 |issue=6 |pages=1064–6 |year=1996 |month=December |pmid=8970567 |doi= |url=}}</ref>, although conservative management has been reported in the literature.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref> There is controversy as to whether to operate immediately or later. The majority of surgeons prefer to operate immediately, and some after a period of conservative management. The timing of surgery depends on the following considerations:
*Surgeon preference
*The timing of presentation
*Comorbidities and fitness for surgery
*The presence of complications
*The hemodynamic status and severity of associated injuries

Surgery is necessary to avoid complications, such as incarceration and strangulation of bowels.<ref name="pmid14735329">{{cite journal |author=Kumar A, Hazrah P, Bal S, Seth A, Parshad R |title=Traumatic abdominal wall hernia: a reappraisal |journal=Hernia |volume=8 |issue=3 |pages=277–80 |year=2004 |month=August |pmid=14735329 |doi=10.1007/s10029-003-0203-4 |url=}}</ref>

Despite the trend to use the laparoscopic approach in treatment of incisional hernias, it infrequently practiced in cases of TAWH.<ref name="pmid12500842">{{cite journal |author=Munshi IA, Ravi SP, Earle DB |title=Laparoscopic repair of blunt traumatic anterior abdominal wall hernia |journal=JSLS |volume=6 |issue=4 |pages=385–8 |year=2002 |pmid=12500842 |pmc=3043450 |doi= |url=}}</ref> Open surgery was selected in most of the reported cases in the literature. Debates exist on whether to use a midline incision or an incision over the hernia. In the majority, midline incision was chosen in acute cases, to rule out associated intra-abdominal injury which occurs in about 30 % to 44% of patients in high energy trauma.<ref name="pmid15227747">{{cite journal |author=Singh R, Kaushik R, Attri AK |title=Traumatic abdominal wall hernia |journal=Yonsei Med. J. |volume=45 |issue=3 |pages=552–4 |year=2004 |month=June |pmid=15227747 |doi= |url=}}</ref> While in low energy induced TAWH, local exploration through an incision over the hernia is preferred.<ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>

The main goal of surgery is reconstruct the disruption of the abdominal wall, which can be achieved either by primary closure or by applying a mesh. It depends on the size and site of hernia, associated intra-abdominal injury and timing of intervention.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref> In TAWH induced by low energy, a primary repair, by approximation of the defect using non-absorbable sutures, was the first choice, because in these cases the soft tissue damage and defect size is minimal.<ref name="pmid15365743">{{cite journal |author=Iinuma Y, Yamazaki Y, Hirose Y, ''et al.'' |title=A case of a traumatic abdominal wall hernia that could not be identified until exploratory laparoscopy was performed |journal=Pediatr. Surg. Int. |volume=21 |issue=1 |pages=54–7 |year=2005 |month=January |pmid=15365743 |doi=10.1007/s00383-004-1264-x |url=}}</ref> On the other hand, in high energy TAWH, the defect size is usually larger and tissue loss is greater, which can’t be repaired primarily. So mesh is preferred, with additional benefit by decreasing the recurrence rate. But not to forget the increased risk of infections in these circumstances.<ref name="pmid12575786">{{cite journal |author=Lane CT, Cohen AJ, Cinat ME |title=Management of traumatic abdominal wall hernia |journal=Am Surg |volume=69 |issue=1 |pages=73–6 |year=2003 |month=January |pmid=12575786 |doi= |url=}}</ref>

==References==
{{Reflist|2}}

[[Category:Surgery]]

{{WH}}
{{WS}}

Traumatic abdominal wall hernia

2012-04-14T17:25:25Z

AwniShahait: /* Treatment */

__NOTOC__
{{SI}}

{{CMG}}; '''Associate Editor-in-Chief:''' [[User:AwniShahait|Awni D. Shahait, M.D.]], The University of Jordan

'''''Synonyms and keywords:''''' TAWH

==Overview==
Traumatic Abdominal Wall Hernia (TAWH) represents an infrequent form of hernia and constitutes 1% of hernia cases.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref>

==Historical Perspective==
The first case was reported by Selby in 1906.

==Epidemiology and Demographics==
There have been 100 cases reported worldwide. The frequency of cases has increased in the last two decades.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref>

==Classification==
Traumatic abdominal wall hernia is generally classified into three types <ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>
#A small abdominal wall defect caused by low-energy trauma with small instruments (e.g. bicycle handlebar)
#A larger abdominal wall defect caused by high-energy transfer such as motor vehicle accident or a fall from a height
#Iintra-abdominal herniation of bowel with deceleration injures (rare)

==Pathophysiology==
TAWH is defined as herniation of viscera occurring after a force is applied to the abdomen in a patient without preexisting abdominal hernia, resulting in disruption of muscles and fascia while maintaining skin continuity. <ref name="pmid16035382">{{cite journal |author=Hardcastle TC, Du Toit DF, Malherbe C, ''et al.'' |title=Traumatic abdominal wall hernia--four cases and a review of the literature |journal=S Afr J Surg |volume=43 |issue=2 |pages=41–3 |year=2005 |month=May |pmid=16035382 |doi= |url=}}</ref> The mechanism of TAWH is thought to be caused by shear stress associated with acute elevation of intra-abdominal pressure. The shear stress is transferred to the peritoneum, fascia and muscle fibers which is then followed by tissue rupture. These injuries are mostly located below the umbilicus due to weaker musculature in that region since the rectus sheath is present only above the arcuate line<ref name="pmid8331706">{{cite journal |author=Gill IS, Toursarkissian B, Johnson SB, Kearney PA |title=Traumatic ventral abdominal hernia associated with small bowel gangrene: case report |journal=J Trauma |volume=35 |issue=1 |pages=145–7 |year=1993 |month=July |pmid=8331706 |doi= |url=}}</ref>. The hernia may occur at a site fremote from the initial site of trauma.<ref name="pmid8970567">{{cite journal |author=Ganchi PA, Orgill DP |title=Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature |journal=J Trauma |volume=41 |issue=6 |pages=1064–6 |year=1996 |month=December |pmid=8970567 |doi= |url=}}</ref> When traumatic insult to the abdominal wall is mainly due to shearing stresses or tensile forces, intra-abdominal injuries are extremely uncommon.<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>

==Diagnosis==
The criteria for diagnosing TAWH were suggested by McWhorten in 1939, and they are<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>:
#Immediate occurrence following blunt trauma
#Severe pain at the site of the injury
#Patient presents within the first 24 hours
#No previous hernia.

Later, these criteria were modified to include:
#Intact Skin over the hernia and
#No evidence of hernial sac during surgery

===Presentation===
The majority of these patients present immediately following the trauma, and 26% present later.<ref name="pmid14735329">{{cite journal |author=Kumar A, Hazrah P, Bal S, Seth A, Parshad R |title=Traumatic abdominal wall hernia: a reappraisal |journal=Hernia |volume=8 |issue=3 |pages=277–80 |year=2004 |month=August |pmid=14735329 |doi=10.1007/s10029-003-0203-4 |url=}}</ref> The classical signs of hernia (i.e., cough impulse and reducibility) are present in only 50% of patients, thus it can be confused with a hematoma. An interesting feature recorded in such a situation is the tendency of such hernias to increase in size over a short period of time.<ref name="pmid3385839">{{cite journal |author=Al-Qasabi QO, Tandon RC |title=Traumatic hernia of the abdominal wall |journal=J Trauma |volume=28 |issue=6 |pages=875–6 |year=1988 |month=June |pmid=3385839 |doi= |url=}}</ref> Bowel sounds can occasionally be heard over such a swelling.

===Imaging===
Ultrasound of the abdominal wall is still widely used because of its availability and relatively low cost. For the first evaluation in the emergency room, the ultrasound is easily accessible and can be helpful for primary diagnoses.<ref name="pmid12090580">{{cite journal |author=Losanoff JE, Richman BW, Jones JW |title=Handlebar hernia: ultrasonography-aided diagnosis |journal=Hernia |volume=6 |issue=1 |pages=36–8 |year=2002 |month=March |pmid=12090580 |doi= |url=}}</ref> However, the sensitivity and specificity of the CT scan is much higher and also enables better imaging of the abdominal wall and the intra-abdominal organs which is of interest in the abdominal trauma patient. At present, CT scan is the standard for diagnosing of any form of abdominal wall hernia since the relationship between the different muscle layers and surrounding structure is better visualized.<ref name="pmid12101537">{{cite journal |author=Hickey NA, Ryan MF, Hamilton PA, Bloom C, Murphy JP, Brenneman F |title=Computed tomography of traumatic abdominal wall hernia and associated deceleration injuries |journal=Can Assoc Radiol J |volume=53 |issue=3 |pages=153–9 |year=2002 |month=June |pmid=12101537 |doi= |url=}}</ref>

==Treatment==
Surgical intervention remains the mainstay of management in these patients<ref name="pmid8970567">{{cite journal |author=Ganchi PA, Orgill DP |title=Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature |journal=J Trauma |volume=41 |issue=6 |pages=1064–6 |year=1996 |month=December |pmid=8970567 |doi= |url=}}</ref>, although conservative management has been reported in the literature.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref> But there is controversy on whether to operate immediately or later. Majority of surgeons prefer to operate immediately, and some after a period of conservative management. When to do the operation depends on some factors, other than the surgeon preference, the timing of presentation, unfitness for surgery, occurrence of complications, hemodynamic status and severity of associated injuries. Surgery is necessary to avoid complications, such as incarceration and strangulation of bowels.<ref name="pmid14735329">{{cite journal |author=Kumar A, Hazrah P, Bal S, Seth A, Parshad R |title=Traumatic abdominal wall hernia: a reappraisal |journal=Hernia |volume=8 |issue=3 |pages=277–80 |year=2004 |month=August |pmid=14735329 |doi=10.1007/s10029-003-0203-4 |url=}}</ref>

Despite the trend to use the laparoscopic approach in treatment of incisional hernias, it still little practiced in cases of TAWH.<ref name="pmid12500842">{{cite journal |author=Munshi IA, Ravi SP, Earle DB |title=Laparoscopic repair of blunt traumatic anterior abdominal wall hernia |journal=JSLS |volume=6 |issue=4 |pages=385–8 |year=2002 |pmid=12500842 |pmc=3043450 |doi= |url=}}</ref> Open surgery was selected in most of the reported cases in the literature. Debates exist on whether to use a midline incision or an incision over the hernia. In the majority, midline incision was chosen in acute cases, to rule out associated intra-abdominal injury which occurs in about 30 % to 44% of patients in high energy trauma.<ref name="pmid15227747">{{cite journal |author=Singh R, Kaushik R, Attri AK |title=Traumatic abdominal wall hernia |journal=Yonsei Med. J. |volume=45 |issue=3 |pages=552–4 |year=2004 |month=June |pmid=15227747 |doi= |url=}}</ref> While in low energy induced TAWH, local exploration through an incision over the hernia is preferred.<ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>

The main goal of surgery is reconstruct the disruption of the abdominal wall, which can be achieved either by primary closure or by applying a mesh. It depends on the size and site of hernia, associated intra-abdominal injury and timing of intervention.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref> In TAWH induced by low energy, a primary repair, by approximation of the defect using non-absorbable sutures, was the first choice, because in these cases the soft tissue damage and defect size is minimal.<ref name="pmid15365743">{{cite journal |author=Iinuma Y, Yamazaki Y, Hirose Y, ''et al.'' |title=A case of a traumatic abdominal wall hernia that could not be identified until exploratory laparoscopy was performed |journal=Pediatr. Surg. Int. |volume=21 |issue=1 |pages=54–7 |year=2005 |month=January |pmid=15365743 |doi=10.1007/s00383-004-1264-x |url=}}</ref> On the other hand, in high energy TAWH, the defect size is usually larger and tissue loss is greater, which can’t be repaired primarily. So mesh is preferred, with additional benefit by decreasing the recurrence rate. But not to forget the increased risk of infections in these circumstances.<ref name="pmid12575786">{{cite journal |author=Lane CT, Cohen AJ, Cinat ME |title=Management of traumatic abdominal wall hernia |journal=Am Surg |volume=69 |issue=1 |pages=73–6 |year=2003 |month=January |pmid=12575786 |doi= |url=}}</ref>

==References==
{{Reflist|2}}

[[Category:Surgery]]

{{WH}}
{{WS}}

Traumatic abdominal wall hernia

2012-04-14T17:07:54Z

AwniShahait: /* Diagnosis */

Traumatic abdominal wall hernia

2012-04-14T16:56:41Z

AwniShahait: /* Pathophysiology */

2012-04-14T11:31:26Z

AwniShahait:

Traumatic abdominal wall hernia

2012-04-14T11:15:58Z

AwniShahait:

==Overview==
Traumatic Abdominal Wall Hernia (TAWH) represents a rare type of hernias in general, with incidence estimated to be 1%.<ref name="pmid17099509">{{cite journal |author=Netto FA, Hamilton P, Rizoli SB, ''et al.'' |title=Traumatic abdominal wall hernia: epidemiology and clinical implications |journal=J Trauma |volume=61 |issue=5 |pages=1058–61 |year=2006 |month=November |pmid=17099509 |doi=10.1097/01.ta.0000240450.12424.59 |url=}}</ref> The first case was reported by Selby in 1906. Till now, about 100 cases have been reported worldwide, with noticed increase in cases in the last two decades.<ref name="pmid21153955">{{cite journal |author=Yücel N, Uğraş MY, Işık B, Turtay G |title=Case report of a traumatic abdominal wall hernia resulting from falling onto a flat surface |journal=Ulus Travma Acil Cerrahi Derg |volume=16 |issue=6 |pages=571–4 |year=2010 |month=November |pmid=21153955 |doi= |url=}}</ref>

TAWH is defined as herniation of viscera occurring after a force is applied on the abdomen in a patient without preexisting abdominal hernia, resulting in disruption of muscles and fascia with maintaining skin continuity. <ref name="pmid16035382">{{cite journal |author=Hardcastle TC, Du Toit DF, Malherbe C, ''et al.'' |title=Traumatic abdominal wall hernia--four cases and a review of the literature |journal=S Afr J Surg |volume=43 |issue=2 |pages=41–3 |year=2005 |month=May |pmid=16035382 |doi= |url=}}</ref> The criteria for diagnosing TAWH were suggested by McWhorten in 1939, and they are: 1- Immediate occurrence following blunt trauma, 2- Severe pain at the site of the injury, 3- Which cause the patient to present in the first 24 hours, 4- No previous hernia. Later, these criteria have been modified to include: Intact Skin over the hernia and no evidence of hernial sac during surgery.<ref name="pmid8114153">{{cite journal |author=Damschen DD, Landercasper J, Cogbill TH, Stolee RT |title=Acute traumatic abdominal hernia: case reports |journal=J Trauma |volume=36 |issue=2 |pages=273–6 |year=1994 |month=February |pmid=8114153 |doi= |url=}}</ref>

Traumatic abdominal wall hernia is generally classified into three types , a small abdominal wall defect caused by low-energy trauma with small instruments (e.g. bicycle handlebar), a larger abdominal wall defect caused by high-energy transfer such as motor vehicle accident or a fall from a height, and rarely intra-abdominal herniation of bowel with deceleration injures.<ref name="pmid2973272">{{cite journal |author=Wood RJ, Ney AL, Bubrick MP |title=Traumatic abdominal hernia: a case report and review of the literature |journal=Am Surg |volume=54 |issue=11 |pages=648–51 |year=1988 |month=November |pmid=2973272 |doi= |url=}}</ref>

==Mechanism==

==Presentation and Diagnosis==

==Management==

==References==
<references/>

[[Category:Surgery]]

Traumatic abdominal wall hernia

2012-04-13T14:33:00Z

AwniShahait: Traumatic Abdominal Wall Hernia

Thyroid cancer

2012-04-13T13:42:55Z

AwniShahait: /* Epidemiology & Demographics */

'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{DiseaseDisorder infobox |
Name = Thyroid cancer |
Image = folladen.jpg |
Caption = This follicular adenoma of the thyroid is shown in a right lobectomy specimen, sectioned vertically and viewed from the posterior aspect to show a 2.7 cm tumor distending the lower pole. Courtesy of Ed Uthman, MD |
ICD10 = C73 |
ICD9 = {{ICD9|193}} |
}}

{{CMG}}
{{MJM}}
{{Thyroid cancer}}
{{Editor Help}}

==[[Thyroid cancer overview|Overview]]==

==[[Thyroid cancer historical perspective|Historical Perspective]]==

==[[Thyroid cancer pathophysiology|Pathophysiology]]==

==[[Thyroid cancer epidemiology and demographics|Epidemiology & Demographics]]==
===Overview===
Although cancers of the thyroid represents about 1% of human malignant neoplasms, it the most common endocrinological malignancy, with about 23,500 cases of thyroid cancer are diagnosed yearly in the United States. The incidence shows a predominance in females with a male:female ratio about 1:1.5 to 1:3 in most countries.<ref name="pmid11991098">{{cite journal |author=Harris PE |title=The management of thyroid cancer in adults: a review of new guidelines |journal=Clin Med |volume=2 |issue=2 |pages=144–6 |year=2002 |pmid=11991098 |doi= |url=}}</ref> The median age for diagnosis is in the third and fourth decades of life.

==[[Thyroid cancer risk factors|Risk Factors]]==

==[[Thyroid cancer screening|Screening]]==

==[[Thyroid cancer causes|Causes]]==

==[[Thyroid cancer differential diagnosis|Differentiating Thyroid cancer]]==

==[[Thyroid cancer natural history|Complications & Prognosis]]==

==Diagnosis==
[[Thyroid cancer history and symptoms|History and Symptoms]] | [[Thyroid cancer physical examination|Physical Examination]] | [[Thyroid cancer staging|Staging]] | [[Thyroid cancer laboratory tests|Laboratory tests]] | [[Thyroid cancer electrocardiogram|Electrocardiogram]] | [[Thyroid cancer x ray|X Rays]] | [[Thyroid cancer CT|CT]] | [[Thyroid cancer MRI|MRI]] [[Thyroid cancer echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Thyroid cancer other imaging findings|Other images]] | [[Thyroid cancer other diagnostic studies|Alternative diagnostics]]

==Treatment==
[[Thyroid cancer medical therapy|Medical therapy]] | [[Thyroid cancer surgery|Surgical options]] | [[Thyroid cancer primary prevention|Primary prevention]] | [[Thyroid cancer secondary prevention|Secondary prevention]] | [[Thyroid cancer cost-effectiveness of therapy|Financial costs]] | [[Thyroid cancer future or investigational therapies|Future therapies]]

==References==
*{{cite journal
| author=Bennedbæk F.N.; Perrild H.; Hegedüs L.
| title=Diagnosis and treatment of the solitary thyroid nodule. Results of a European survey
| journal=Clinical Endocrinology
| year=1999
| volume=50
| issue=3
| pages=357–363}}
*{{cite journal
| author=Carlo Ravetto, Luigia Colombo, Massimo E. Dottorini
| title=Usefulness of fine-needle aspiration in the diagnosis of thyroid carcinoma
| journal=Cancer Cytopathology
| year=2000
| volume=90
| issue=6
| pages=357–363}}
*{{cite journal
| author=Jacques Barbet, Loïc Campion, Françoise Kraeber-Bodéré, Jean-François Chatal, and the GTE Study Group
| title=Prognostic Impact of Serum Calcitonin and Carcinoembryonic Antigen Doubling-Times in Patients with Medullary Thyroid Carcinoma
| journal=The Journal of Clinical Endocrinology & Metabolism
| year=2005
| volume=90
| issue=11
| pages=6077-6084}}

== See also ==

*Chernobyl disaster ([[radioactive contamination]] is a cause of thyroid cancer)

==External links==
* [http://www.bidmc.org/YourHealth/ConditionsAZ.aspx?ChunkID=11507 Beth Israel Deaconess Medical Center: Thyroid cancer]
* {{dmoz|/Health/Conditions_and_Diseases/Cancer/Endocrine/Thyroid/|Thyroid cancer}}
* [http://www.thyroidtrials.org Thyroid Cancer Clinical Trials Page] of the American Thyroid Association
* [http://www.nucmedinfo.com/Pages/thyroid.html Nuclear Medicine Information =– Thyroid Diseases]
* [http://www.cancer.gov/cancertopics/types/thyroid Thyroid Cancer]- National Cancer Institute
* [http://www.thyca.org] - Thyroid Cancer Survivors' Association

{{Tumors}}
{{SIB}}
[[bs:Rak štitne žlijezde]]
[[de:Schilddrüsenkrebs]]
[[es:Cáncer tiroideo]]
[[fr:Cancer de la thyroïde]]
[[hr:Rak štitnjače]]
[[it:Tumore della tiroide]]
[[he:סרטן בלוטת התריס]]
[[nl:Schildklierkanker]]
[[ja:甲状腺癌]]
[[no:Skjoldkjertelkreft]]
[[pt:Tumor da tiróide]]
[[simple:Thyroid cancer]]
[[fi:Kilpirauhassyöpä]]
[[sv:Sköldkörtelcancer]]
[[vi:Ung thư tuyến giáp]]
[[tr:Tiroid kanseri]]
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[[Category:Thyroid disease]]
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