Insights into pathophysiology
The rectus abdominis diastasis
The rectus muscles are normally kept close to each other by the linea alba, which being a very robust structure, ensures proper spacing during increases in abdominal pressure and proper function during contraction. In some specific conditions such as pregnancy, overweight or excessive repeated efforts over time, the linea alba may undergo athinning and an overall enlargement of its surface with the microscopic and macroscopic anatomical subversion of its fibers.
This condition gives rise to a pathologic distancing of the rectus abdominis muscles called rectus abdominis diastasis abdomen o diastasis recti. diastasis recti is therefore a pathologic condition of a nature tendon-connective that, contrary to what some patients think, does not directly affect the muscle. The rectus abdominis musclesare only secondarily affected by the pathology, as they are no longer able to maintain proper alignment and distance; this reduces their effectiveness, their structural restraining effect as well as the contractile force generated.
Through the area affected by diastasis, during the increase of abdominal pressure it is possible to perceive the protrusion of the viscera and sometimes, at rest, even to glimpse the intestinal peristalsis (especially in people with low panniculus adiposus).
Diastasis by definition, is not a hernia, since there is continuity of the various layers of the abdominal wall (even if ineffective and thinned). In fact, in clinical practice, rectus abdominis diastasis is frequently associated with umbilical hernias or even multiple hernias of the abdominal midline, being the precursor or the aggravating factor. For the clinical and therapeutical part regarding rectus abdominis diastasis please refer to specific chapters.
INGUINAL HERNIA
Introduction
Inguinal hernia occurs when the structures of the inguinal canal give way and the contents of the abdominal cavity tend to leak out through the area of weakness that is created.
Indirect or external oblique inguinal hernia
Indirect inguinal hernia, also called external oblique, originates through a congenital or acquired failure of the internal inguinal ring and inguinal canal.
With some frequency, indirect inguinal hernias are sustained by a developmental defect in fetal age, where a particular eversion of parietal peritoneum (the peritoneo-vaginal duct) that normally closes independently with growth remains pervious.
Other indirect hernias are acquired as a result of weakening of the internal inguinal ring and the posterior wall of the inguinal canal.
Direct inguinal hernia
Direct inguinal hernia is an acquired hernia and originates from a weakening of the posterior wall of the inguinal canal. This weakening originates medially to the inferior epigastric vessels. Over time, as it enlarges, the direct hernia makes its way through the inguinal canal to escape by also deforming the anterior wall of the inguinal canal and the external inguinal ring. At this late stage, direct hernias strongly resemble indirect hernias.
Therapies
CRURAL HERNIA
Thecrural or femoral hernia makes its way through a pathway called the femoral canal. With the formation of the hernia gives way to a septum of connective tissue that normally makes the femoral ring closed, the structure therefore becomes transitable by inappropriate content such as adipose or intestine in the most severe cases. The opening that is created is delimited anteriorly by the inguinal ligament, posteriorly by the pectoral ligament, medially by the curved lateral margin of the lacunar ligament and laterally by the femoral vein. In females, the ring is larger than in males and is stressed during pregnancy, in fact crural hernia is more frequent in females than in males.
Crural hernia is sometimes difficult to diagnose because it is typically small in size and remains masked by subcutaneous fat. It would also seem that the small size of the hernial orifice increases the likelihood of major complications such as strangulation.
Therapies
For the clinical and therapeutic part regarding crural hernia, please refer to the specific chapter.
UMBILICAL HERNIA
Umbilical hernia results from a poor closure, weakening, or loss of substance of the structures that make up the umbilicus.
Most umbilical hernias in adults are acquired in nature and related to increased volume/pressure in the abdominal cavity, situations that typically occur in pregnancy, obesity, or excessive physical strain.
Frequently, post-pregnancy umbilical hernia is associated with the presence of rectus abdominis diastasis, so an accurate diagnosis is necessary before planning a simple hernial repair that might otherwise result in an incomplete and fragile reconstruction.
There are also congenital umbilical hernias due to disorders of fetal development where there is a poor closure of the structures or even a lack of substance of the abdominal part, these particularly severe hernias are called omphaloceles.
Therapies
SPIGELIAN HERNIA
Spigelium hernia is formed by protrusion of pre-peritoneal fat and parietal peritoneum through subsidence of the Spigelium region (region where the semilunar line joins the arcuate line).
It is aninterstitial hernia because it makes its way between the aponeurosis of the transverse and internal oblique muscles but remains masked by the aponeurosis of the external oblique muscle, which is almost always undamaged or deformed. This aspect makes Spigelio's hernia often difficult to clinical diagnosis.
Therapies
INCISIONAL HERNIA OR LAPAROCELE
Laparocele is a complication at the site of a previous abdominal surgical incision. It can occur as a result of defective closure technique, wound infection, and patient-related factors such as comorbidities, obesity, and advanced age.
The regions most frequently affected by laparoceles are also those most prone to eventual surgical incisions. Therefore, midline laparoceles are frequently found in traditional abdominal surgery. On the other hand, subcostal laparoceles are less frequently found in hepatobiliary surgery or lumbar laparoceles in retroperitoneal surgery.
When the laparocele is located in a region particularly adjacent to a bony prominence we speak of borderline laparocele, a type of laparocele particularly delicate to treat, as well as delicate to treat those cases where the previous surgery has caused an atrophy or a loss of substance of the abdominal wall, which is often difficult to replaceable.
Therapies
For the clinical and therapeutic part regarding laparocele, please refer to the specific chapter.
