RARE HERNIAS (1) Lumbar Hernia

1. RARE HERNIAS (1) Lumbar Hernia This is a hernial protrusion through “Petit triangle” which is bounded below by the iliac crest, laterally by the external oblique and medially by the latissimusdorsi The hernia forms a soft reducible swelling which has to be differentiated from a lumbar abscess and lipoma Treatment:The hernia can be controlled by a belt, but if large or causing symptoms, operative repair by suturing or grafting may be carried out

2. (2) Obturator Hernia • This hernia is very rare, and most patients are elderly females. The sac passes through the obturator foramen to lie between the obturatorexternus and pectineus, superficial to the obturator vessels • It usually forms no external swelling, and is often overlooked until strangulation occurs and the abdomen is explored • Treatment is by transabdominal repair. After reduction of the contents, the sac is excised and the Obturator canal is obliterated by sutures

3. (3) Gluteal and Sciatic Hernias • Gluteal hernia protrudes through the greater sciatic notch, and sciatic hernia through the lesser sciatic notch • They may form a palpable swelling which should be differentiated from gluteal lipoma, aneurysm or cold abscess. More often, they remain unnoticed until discovered at laparotomy for intestinal obstruction • Treatmentis by transabdominal repair

4. (4) Pelvic Hernias These rare hernias may protrude through the pelvic floor at the pouch of DougIas (median pelvic hernia) or at the foramen of Schwalbe" which is a gap in the line of origin of the Levatorani from the obturator fascia (lateral pelvic hernia) Treatmentis by transabdominal repair.

5. (5) Diaphragmatic Hernias • These hernias may protrude through congenital, anatomical, traumatic or pathological defects in the diaphragm • The most important variety is esophageal hiatus hernia • Treatment:The loop is untwisted and the causative lesion is dealt with. If the gut is non-viable, resection-anastomosis is carried out

6. Internal hernias Internal hernias may occur through : (a) Bandsusually arise by stretching and metamorphosis of fibrous adhesions. They may be peritoneal, omental or visceral and may make arches through which the bowel prolapses or may form snares which trap or "lasso" a loop of gut (b) Peritoneal holes:A loop of bowel may herniate through a hole in the mesentery, mesocolon, mesosigmoid, great omentum, gastrohepaticomentum, falciform ligament or broad ligament (c) Parietal foramina:Internal hernia may occur through the foramen of Winslow, the obturator foramen or the diaphragmatic foramina (d) Retroperitoneal fossaeare related to the duodenum, caecum or sigmoid

7. The duodenal fossaeare five in number • The paraduodenal fossa lies to the right of the duodenojejunal flexure and opens to the right with the inferior mesenteric vein ascending in its anterior free margin • The superior duodenal fossa opens downwards and lies behind a transverse fold which extends from the duodenoojejunal flexure to the inferior messenteric vein • The inferior duodenal fossa opens upward and lies behind a similar fold which extends at a lower level than that of the previous • The retroduodenal fossa extends behind the third part of the duodenum and its mouth opens downwards • The mesentericoparietal fossa lies behind the root of the mesentery and superior mesenteric vessels and its mouth opens to the left

8. 2. The paracecal fossae • are three in number: • The superior ileocecal fossa lies behind the superior ileocecal fold (vascular fold of the caecum) which contains the ileocecal vessels • The inferior ileocaecal fossa lies behind the inferior ileocecal fold (bloodless fold of Treves) • The retrocecal fossa lies behind the caecum and ascending colon • 3. The intersigmoid fossa • Extends upwards and to the right behind the sigmoid vessels and its mouth opens downwards and to the left