Hernia prone to reoccur after primary repair:

Ref: Sahiston Textbook of Surgery; 19th Edition, Pg: 3/. 1135. & Bailey & Love's Short Practice of Surgery, 25th Edition, 979.Explanation:- Incisional hernias have the highest recurrence rate if managed with primary repair.Incisional HerniaPrimary repair of incisional hernias can be doneWhen the defect is small <d"2 to 3 cm in diameter) and there is viable surrounding tissueIn cases in which the hernia was clearly a result of a technical error at the initial operation, such as a suture fracturing.Larger defects (>2 to 3 cm in diameter) have a high recurrence rate if closed primarily and are repaired with a prosthesis.Recurrence rates vary between 10% and 50% and are typically reduced by more than 50% with the use of prosthetic mesh.Epigastric hernias2-3 times more common in men.Located between the xiphoid process and umbilicus and are usually within 5 to 6 cm of the umbilicus.Common in individuals with a single aponeurotic decussation.The defects are small and often produce pain out of proportion to their size because of incarceration of preperitoneal fat.Multiple in up to 20% of patients and approximately 80% are in the midline.Repair usually consists of excision of the incarcerated preperitoneal tissue and simple closure of the fascial defect, similar to that for umbilical hernias.Small defects can be repaired under local anesthesia.Uncommonly, these defects can be sizable, can contain omentum or other intra-abdominal viscera, and may require mesh repairs.Spigelian herniaIt occurs through the spigelian fascia, which is composed of the aponeurotic layer between the rectus muscle medially and semilunar line laterally.Almost alt spigelian hernias occur at or below the arcuate line.The absence of posterior rectus fascia may contribute to an inherent weakness in this area.These hernias are often interparietal, with the hernia sac dissecting posterior to the external oblique aponeurosis.Clinical features and diagnosisMost Spigelian hernias are small 11 to 2 cm in diameter) and develop during the 4-7th decades of life.Patients often present with localized pain in the area without a bulge because the hernia lies beneath the intact external oblique aponeurosis.Ultrasound ur CT of the abdomen can be useful to establish the diagnosis.ManagementA spigelian hernia is repaired because of the risk for incarceration associated with its relatively narrow neck.The hernia site is marked before operation.Larger defects are repaired using mesh prosthesis.Recurrence is uncommonFemoral herniaA femoral hernia occurs through the femoral canal, which is bounded superiorly by the iliopubic tract, interiorly by Cooper's ligament, laterally by the femoral vein, and medially by the junction of the iliopubic tract and Cooper's ligament (lacunar ligament!.Recurrence of femoral hernia after operation is only 2%.There are three approaches to femoral hernia repair.The low operation (Lockwood). The sac is dissected out below the inguinal ligament via a groin crease incision.The high (McEvedy) operation Classically, a vertical incision is made over the femoral canal and continued upwards above the inguinal ligament.Lotheissen's operation (Inguinal Approach)The inguinal canal is opened as for inguinal herniorrhaphy.