SUPRAUMBILICAL HERNIA WITH DIVERICATION OF RECTI

1. SURGERY CASE PRESENTATION
A CASE OF
VENTRAL
HERNIA

2. A CASE OF
VENTRAL
HERNIA

3. PRESENTED BY

4. HISTORY

5. PATIENT’S PARTICULARS
Name – Karthik Rajbongshi Hospital no. – 211168/16
Age – 26 years Deptt. Regd. No. – 16675/16
Sex – Male Ward – Surgery
Religion – Hinduism Unit – MSU II+V
Address – C/O Karuna Rajbongshi, Bed no. – 31
Village: Kathalbari,
P.S.- Nalbari,
District- Nalbari,
Ph. No.- 9018142488
Occupation – CRPF Personnel
Marital Status – Bachelor
Date of Admission – 1/7/2016
Date of Examination – 4/7/2016

6. CHIEF COMPLAINTS
 Abdominal swelling for 18 years.
 Pain abdomen for 4-5 months.

7. HISTORY OF PRESENT ILLNESS
 The patient complains of a lump in the abdomen along the
midline just above the umbilicus which he first noticed when he
was 8-9 years of age and ignored it. It resembled a marble then.
 Suddenly 4-5 months back, he felt pain in the umbilical region
along the midline when he noticed that the lump had then rapidly
increased to the size of a betel-nut. It becomes prominent on
coughing or straining such as on strenous exercise and reduces
spontaneously on lying down on the bed.
 The pain is an intermittent dull-ache, moderate in intensity,
aggravated on straining and relieved on leaning forward. There is
no radiation of the pain.

8. HISTORY OF PRESENT ILLNESS
 There is no vomiting, no yellowish discolouration of eyes or
urine, no chronic cough or constipation or abdominal
distension.
 The bowel, bladder habits are normal, sleep is normal and
the appetite is good. There is no loss of weight.
 The patient was referred to GMCH from a CRPF hospital
and after the necessary investigations, he has been called for
surgery at a later date.

9. HISTORY OF PAST ILLNESS
 The patient has no history of similar swelling in the past,
elsewhere in the body.
 The patient has no history of respiratory problems such as
asthma, cardiac ailments, tuberculosis, diabetes, hypertension,
malaria or any surgical history in the past.

10. PERSONAL HISTORY
 The patient is a non-vegetarian and consumes an average
Assamese diet. He does not consume any intoxicants.

11. FAMILY HISTORY
 The patient’s family presents with no similar complaints.
No disease runs in the family.

12. SOCIOECONOMIC HISTORY
 The patient lives in a pucca house in a 3 membered nuclear
family with his parents and a younger brother.
 He is the sole earning member with a monthly income of Rs
18000 and a per capita income of Rs 6000. They use LPG
cylinder as the fuel source for cooking.
 They consume tubewell water after filtration.

13. DRUG AND ALLERGY HISTORY
 There is no routine consumption of any drug.
 There is no history of allergy to any known contactant,
ingestant or inhalant.

14. IMMUNISATION HISTORY
 The patient could not specify his immunisation history.
 No BCG scar seen.

15. GENERAL
EXAMINATION

16. • Consciousness- The patient is alert and conscious
• Orientation- Well oriented to time, place and person
• Appearance and Facies- Normal
• Decubitus- Of choice
• Build- Average
• Nutrition- Good
• Gait- Normal
• Pallor- Absent
• Icterus- Absent
• Cyanosis-Absent
• Clubbing- Absent
• Dehydration -Absent
• Neck Veins- Not engorged
• Lymph nodes- Not palpable
• Edema- Absent
• Hair ,skin and nails- Normal
• Oral Cavity- Oral hygiene is maintained, no features of malnutrition, no dental caries,
gums , tongue is moist with normal papillae

17. VITALS
• PULSE-
1. Rate- 84 beats/ min
2. Rhythm- regular
3. Character- normal
4. Volume- normovolumic
5. Radioradial or Radiofemoral delay- Absent
6. All peripheral pulses- Palpable
7.Elasticity of arterial wall- present
• BLOOD PRESSURE- 120/72 mm Hg in left arm taken in supine position
• RESPIRATORY RATE- 18/ min, regular, abdominothoracic.
• TEMPERATURE- 98˚F

18. OTHER
SYSTEMIC
EXAMINATION

19. CENTRAL NERVOUS SYSTEM
a) Higher function: The patient is alert, conscious, cooperative and well oriented to time,
place and person.
b) Cranial Nerves: Functions of all the cranial nerves are intact.
c) Motor system: Tone, power and bulk of muscles of all four limbs are normal.
Coordination is normal. No abnormality detected. All the superficial and deep
reflexes are intact.
d) Sensory and autonomic functions are normal.

20. CARDIOVASCULAR SYSTEM
a) Inspection: Precordium is normal. No visible pulsations or engorged veins seen. No
scar is seen.
b) Palpation: Apex beat is palpable just medial to mid-clavicular line in the left 5th
intercostal space. It is normal in character.
c) Auscultation: Heart sounds are normal. No added sounds heard.

21. RESPIRATORY SYSTEM
a) Inspection: Shape and symmetry of chest is normal and symmetrical. Respiratory
movements are bilaterally symmetrical. Respiratory rate is 18/minute and regular in
rhythm. No deformity detected.
b) Palpation: Trachea is in midline. Chest expansion is normal and bilaterally
symmetrical on both sides. Vocal fremitus is bilaterally symmetrical and normal.
c) Percussion: Lung field is uniformly resonant in all the areas. No abnormality
detected.
d) Auscultation: Normal breath sounds are heard in all the areas. Vocal resonance is
normal and bilaterally symmetrical in all the areas. No added sounds heard.

22. ABDOMINAL
EXAMINATION

23. INSPECTION
a) Shape and contour of abdomen – Normal.
b) Umbilicus – Inverted, midline in position and midway
between the xiphisternum and pubic symphysis.
c) Skin over the abdomen – No scar, abnormal pigmentation
or engorged veins seen.
d) Movement of abdomen with respiration – All regions are
moving normally with respiration.
e) Any visible peristalsis – None.
f) Any visible pulsations – None.

26. INSPECTION
g) Prominent divaricated edges of both recti along with visi
ble mass is seen.
 Site – present in the supraumbilical region along the
midline.
 Shape – oval in shape.
 Surface – Smooth.
 Margins – Well defined.
 ‘Leg rising test’ and ‘Head rising test’ – the visible
swelling becomes more prominent, hence it is a PARIETAL
SWELLING.
 Cough Impulse Test – Expansile impulse on cough is
present.
 Any ulceration or skin changes over the defect – None.

27. INSPECTION
h) Inspection of other hernia sites – No swelling and no
expansile impulse on coughing is seen.
i) Inspection of external genitalia – Normal.

28. SUPERFICIAL PALPATION
a) Temperature – No local rise of temperature.
b) Superficial tenderness – Tenderness is present in the umbilical region
over the area of the defect as well as in the midline.
No tenderness present in any of the other areas.
c) Feel of abdomen – Soft and elastic.
d) Any muscle guarding and rigidity – None.
e) Palpation of swelling :-
 Site and extent – midline in position just over the umbilicus.
 Size – 3x4 cm.
 Shape – Oval.
 Surface – Smooth.
 Margin – Well-defined.
 Reducibility of swelling – Swelling is reducible.
 Cough impulse test – Positive.
 Consistency – Soft, doughy feel on knee elbow position.
 Pulsation – none.
 Compressibility of swelling – Not compressible on knee elbow
position.
 Fluctuation – Absent on knee elbow position.

29. DEEP PALPATION
a) Tenderness – tenderness present only over the defect and in midline, no
tenderness over any of the other areas.
b) Palpation of liver – Not palpable.
c) Palpation of spleen – Not palpable.
d) Palpation of kidneys – Not palpable.

30. PERCUSSION
a) General percussion note over the abdomen – Tympanitic.
b) Percussion note over the swelling – Dull.
c) Shifting dullness – Absent.
d) Fluid thrill – Absent.
e) Liver span – 12.5 cm, upper border in the right 5th
intercostal space.

31. AUSCULATATION
a) Auscultationovertheswelling –nobowelsoundsheard.
b) Peristalticsoundintheotherareas–Presentand normal.
c) Bruit–Absentinanyareas.

32. PER RECTAL EXAMINATION
 Not done.

33. PROVISIONAL
DIAGNOSIS

34. Our patient Karthik Rajbongshi, 26 years old Male is
provisionally diagnosed to be a case of PARAUMBILICAL
HERNIA IN THE SUPRAUMBILICAL REGION OF THE
ABDOMEN, PROBABLY AN OMENTOCELE WITH
DIVERICATION OF RECTI.

35. DIFFERENTIAL
DIAGNOSIS

36. 1. Congenital weakness of rectus sheath.
2. Congenital absence of rectus.

37. INVESTIGATIONS

38. HAEMATOLOGY
WBC 8.01 (10^3/uL) (WNL)
Haemoglobin 16.2 (g/dl) (WNL)
Platelet 205 (10^3/uL) (WNL)
Neutrophil 58.9% (WNL)
Lymphocyte 31.7% (WNL)
Monocyte 8.4% (WNL)
Eosinophil 1% (WNL)
ESR 14 (mm After 1 Hour)
Prothrombin(control 13 seconds ) 14.8sec
PT-INR 1.24

39. SERUM SAMPLE
- Glucose-Random 79 (mg/dl) (LOW)
- Urea 30 (mg/dl)
- Creatinine 1.0(mg/dl)
- Sodium 144(mmol/l)
- Potassium 4.6(mmol/l)
- Total Bilirubin 1.10(mg/dl)
- Conjugated Bilirubin 0.0(mg/dl)
- Unconjugated Bilirubin 0.7(mg/dl)
- Delta Bilirubin 0.4(mg/dl) (HIGH)
- AST 35 (U/L)
- ALT 47 (U/L)
-ALKP 65 (U/L)
-Total Protein 8.5(g/dl) (HIGH)
-Albumin 5.1(g/dl) (HIGH)
-Globulin 3.4(g/dl)
-A/G Ratio 1.5

40. SERUM SAMPLE
- Hepatitis B Virus (HBsAg TEST) NON REACTIVE
- Hepatitis c Virus (Anti-HCV antibody test) NON REACTIVE
- HIV NON REACTIVE
- Serum TSH 2.02mIU/L

41. RADIOLOGY
X-Ray Chest PA View
-Both the lung fields do not reveal any active parenchymal lesions.
-Trachea is normal in position.
-Hilar shadows are normal.
-Cardiothoracic ratio is normal.Great vessels are within normal limits.
-CP angles are clear and acute.
-Both domes of diaphragm are normal in position and contour.
-Bony thorax is intact.

42. RADIOLOGY
Ultrasonography:
Report is currently not available but according to the consulting doctors who have gone through
thepreviousreports,thereissomedefectintheanteriorabdominalwallwithherniation.

43. FINAL
DIAGNOSIS

44. “Our patient Karthik Rajbongshi, 26 years old Male is finally
diagnosed to be a case of PARAUMBILICAL HERNIA IN
THE SUPRAUMBILICAL REGION OF THE ABDOMEN
WITH AN OMENTOCELE WITH DIVERICATION OF
RECTI.”

45. MANAGEMENT

46. THE MANAGEMENT IS PRIMARILY
SURGICAL
1. Primary Closure Of The Defect- An infraumbilical incision is made encircling its lower
half. Sac is dissected circumferentially and is released of from the umbilicus ande
subcutaneous tissue. Sac is opened ; contents are reduced ;excess part is excised up to the
umbilical ring. Defect is closed with interupted nonabsorbable suture.
2. Mayo's Operation- Through a transverse elliptical incision sac is identified and
dissected . Herniotomy is done. Double breasting of the defect in the rectus sheath is
done by interrupted non-absorbable suture.

47. THE MANAGEMENT IS PRIMARILY
SURGICAL
3. Open Dual PTFE and Polypropylene Mesh Placement-
Umbilical hernia is dissected similarly through subumbilical
incision. Redundant sac is excised. Peritoneum is closed. A
special composite mesh containing wider PTFE on the inner
side with little smaller polypropylene mesh on the outer aspect
is used.
4. Laparascopic Umbilical Hernia Repair- It is similar to
any ventral hernia , done under GA. It is usually done for large
umbilical hernia.

49. SUMMARY