Hernias and Surgery of the abdominal wall by E. GoldsteinHernias and Surgery of the abdominal wall by E. Goldstein

Hernias and Surgery of the abdominal wall

byE. GoldsteinEditorJean-Paul ChevrelTranslated byE. Goldstein

Paperback | April 18, 2012

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The result of a European-American co-operation, whose joint efforts have dramatically reduced the rate of recurrent groin hernia, burst abdomen and incisional hernia in patients.
The contributors to this updated volume are among the most renowned specialists in the field and here they present personal accounts of the once controversial techniques they have now perfected.
New sections have been added to include such revolutionary techniques as prosthetic mesh and laparoscopic surgery.
Title:Hernias and Surgery of the abdominal wallFormat:PaperbackDimensions:340 pages, 27.9 × 21 × 0.01 inPublished:April 18, 2012Publisher:Springer NatureLanguage:English

The following ISBNs are associated with this title:

ISBN - 10:3642488838

ISBN - 13:9783642488832

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Table of Contents

1. General.- 1. Surgical Anatomy of the Anterolateral and Posterior Abdominal Walls and Points of Weakness.- I. The Anterolateral Abdominal Wall.- A. Cutaneous and Subcutaneous Layer.- B. Vascularization of the Cutaneous Layers of the Abdomen.- 1. Arterial Vascularization.- 2. Venous Drainage.- 3. Lymphatic Drainage.- C. Myofascial Layer.- 1. Rectus Abdominis.- Structure.- 2. Oblique and Transversus Muscles.- a) External Oblique.- b) Internal Oblique.- c) Transversus Abdominis Muscle.- (1) Transversalis Fascia.- (2) Fascia Propria.- 3. Rectus Sheath (Vagina Recti Abdominis).- a) Arcuate Line (Semicircular Line of Douglas).- b) Adhesion of the Rectus Abdominis to the Laminae of its Sheath.- 4. Linea Alba.- 5. Semilunar Line (Spigelius Line).- D. Vascularization of the Muscle Layers of the Anterolateral Abdominal Wall.- 1. Arterial Vascularization.- 2. Venous Drainage.- 3. Lymphatic Drainage.- E. Innervation of the Anterolateral Abdominal Wall.- 1. Superficial Layers.- 2. Deep Layers: Motor Innervation of the Parietal Muscles.- 3. Neural Anastomoses and Metamerization.- II. Weak Points of the Anterolateral Abdominal Wall.- A. Umbilicus.- 1. Outer Aspect.- 2. Structure.- a) Umbilical Ring.- b) Round Ligament of the Liver.- c) Umbilical Arteries.- d) Urachus.- e) Umbilical Fascia.- f) Umbilical Peritoneum.- 3. Vascularization and Innervation of the Umbilical Region.- a) Arteries.- b) Veins.- c) Lymph Vessels.- d) Nerves.- B. Inguinal Region.- 1. Outer Layer.- 2. Aponeurosis of the External Oblique Muscle of the Abdomen.- 3. Deep Myofascial Layer - The Myopectineal Orifice.- a) Components of the Fibromuscular Frame.- (1) Medial Margin.- (2) Superior Margin.- (3) Inferior Margin.- b) Umbilicoprevesical Fascia and Inguinal Peritoneum.- C. Other Weak Points of the Anterior Abdominal Wall.- 1. Linea Alba.- a) Radiological Study.- b) Functional Study.- 2. Semilunar Line.- III. The Posterior Abdominal Wall.- A. Deep Layer.- 1. Median Spinal Axis.- 2. Lateral Spinal Muscles.- a) Iliopsoas Muscles.- b) Quadratus Lumborum Muscle.- 3. Vascularization and Innervation of the Deep Muscle Layer of the Posterior Abdominal Wall.- a) Arterial Vascularization and Venous Drainage.- b) Lymphatic Network.- c) Innervation.- 4. Site of Emergence of the Terminal Branches of the Lumbar Plexus in Relation to the Iliopsoas Muscle.- 5. Action of the Deep Muscles of the Posterior Abdominal Wall.- B. Superficial Layer of the Posterior Abdominal Wall.- 2. Functional Anatomy of the Muscles of the Anterolateral Abdominal Wall: Electromyography and Histoenzymology - Relationship Between Abdominal Wall Activity and Intra-abdominal Pressure.- I. Detailed Study of Structure: Histochemical Analysis of the Fibers of the Abdominal Wall.- A. Material and Methods.- B. Results.- C. Functional Deductions.- II. Detailed Study of Function: Quantitative Kinesiological Electromyography of the Abdominal Wall Musculature.- A. Principles of the Method.- 1. Automatic Analysis of the Recordings.- 2. Selection of Muscle Activities Within Narrow Frequency Spectra.- B. Overall Results and Tentative Interpretation.- C. Results of the Method Applied to the Study of the Function of the Abdominal Wall Muscles.- 1. Technique.- 2. Comparative Performance of the Rectus and Flat Abdominal Muscles According to Study Subgroup.- a) Assessment of Performance.- b) Results According to Subject Category.- III. Study of Intra-abdominal Pressure in Operated Patients.- A. History.- B. Materials and Methods.- C. Results.- 1. Baseline Pressure.- a) First Postoperative Day.- b) Fourth Postoperative Day.- 2. Respiratory Modifications.- 3. Effort of Defecation with Blocking of Expiration.- 4. Modulation of Abdominal Pressure by Speech.- 5. Effects of Coughing on Abdominal Pressure.- D. Comments.- IV. Correlation of the Activity of the Diaphragm and Abdominal Wall Muscles with Intra-abdominal Pressure.- A. Material and Methods.- B. Results.- 1. With Normal Respiration.- 2. With Deep Inspiration.- 3. During Effort of Coughing.- 4. Infra-abdominal Pressure and Circulatory Physiology.- V. Conclusions and Surgical Applications.- 3. Procedures for Investigation of the Abdominal Wall.- I. Echography of the Abdominal Wall.- A. Technique of Echographic Investigation.- B. Echographic Anatomy of the Abdominal Wall.- 1. Epidermis and Dermis.- 2. Hypodermis.- 3. Muscles of the Abdominal Wall.- 4. Sheaths and Aponeuroses.- 5. Peritoneum.- C. Echography of the Pathological Abdominal Wall.- 1. Parietal Collection of Fluid.- 2. Hernia.- 3. Incisional Hernia.- 4. Tumor.- 5. Spontaneous Hematoma of the Rectus Sheath.- 6. Other Anomalies Seen on Echography.- 7. Postoperative Investigation.- 8. Doppler Studies.- D. Conclusion.- II. Computed Tomography of the Abdominal Wall.- A. Computed Tomography of the Normal Abdominal Wall.- B. Computed Tomography of the Pathological Abdominal Wall.- 1. Tumor Masses.- a) Benign Tumors.- b) Malignant Tumors.- 2. Inflammatory Lesions.- 3. Abdominal Wall Hernias.- C. Conclusion.- 2. Surgical Techniques.- 4. Surgical Approaches to the Abdomen.- I. Anterior Incisions.- A. Longitudinal.- 1. Supraumbilical Midline Laparotomy.- 2. Subumbilical Midline Laparotomy.- 3. Combined Supra- and Subumbilical Midline Laparotomy.- 4. Paramedian Laparotomy.- a) Transrectus Incision.- b) Lateral Pararectus Incision.- c) Medial Pararectus Incision.- B. Transverse.- 1. Right Transverse Subcostal.- 2. Left Transverse Subcostal.- 3. Bilateral Transverse Supraumbilical.- 4. Right Paraumbilical.- 5. Left Transverse Paraumbilical.- 6. Transverse Incision of Right Iliac Fossa.- 7. Pfannenstiel's Transverse Suprapubic.- Variations on Pfannenstiel's Incision.- C. Oblique.- 1. Subcostal.- 2. Bilateral Subcostal.- 3. McBurney's.- 4. Inguinal.- II. Lateral and Posterior Incisions.- A. Lumbar Route.- B. Anterolateral Approaches.- 1. Oblique Anterolateral Incision.- 2. Other Horizontal Incisions.- 3. Iliac Incision.- III. Thoracoabdominal Incisions.- A. Midline Abdominal Incision with Sternotomy.- B. Midline Abdominal Incision with Extension to Thoracophrenolaparotomy.- C. Oblique Abdominal Incision with Extension to Thoracophrenolaparotomy.- IV. Selection of an Incision.- A. Operative Exposure.- B. Disadvantages of Laparotomy.- 1. Parietal Complications.- 2. Pulmonary Complications.- V. Procedures for Closure.- A. Layers to be Sutured.- 1. Peritoneal Layer.- 2. Fascial Layer.- a) Interrupted Versus Continuous Sutures.- b) Selection of Suture Material.- 3. Muscle Layer.- 4. Subcutaneous Layer.- 5. Cutaneous Layer.- B. Special Cases.- VI. Laparoscopic surgery.- A. The Pneumoperitoneum.- 1. Insufflation.- a) Uncomplicated Situations.- b) Suspension of the Abdominal Wall.- 2. The Trocars.- B. General Principles of the Laparoscopic Approach.- 1. Orientation.- 2. Disposition.- 3. Adaptation.- 4. Open Laparoscopy.- 5. "Laparo-assisted" Surgery.- 6. Advantages of Laparoscopy.- C. Complications of Laparoscopic Surgery.- 1. Complications of the Pneumoperitoneum.- 2. Complications Related to the Trocars.- 3. Postoperative Complications.- a) Early.- b) Secondary.- c) Late.- D. Conclusion.- 5. Pre- and Postoperative Care.- I. Preparation for Surgery of the Abdominal Wall.- A. General.- B. Skin.- C. Respiratory Apparatus.- II. Postoperative Care.- A. Drainage of the Abdominal Wall.- B. Transcutaneous Electrical Stimulation for Pain.- 6. Postoperative Complications.- I. Early Complications Involving the Abdominal Wall.- A. Hematoma.- B. Abscess.- C. Seroma.- 1. Preventive Treatment.- 2. Curative Treatment.- II. Residual Pain Subsequent to Laparotomy.- A. Pathophysioloy.- 1. Painful Stimuli.- 2. Subjective Pain.- 3. Muscular and Vegetative Reflex Response to Pain.- 4. Emotional Reaction.- 5. Behavioral Reaction.- B. Clinical Findings in Chronic Pain.- 1. Peripheral Nerve Lesion.- a) Pain of Neuroma.- b) Deafferentation Pain.- 2. Projected Pain.- a) Reported Pain Along an Intact Nerve.- b) Referred Pain at a Distance from the Lesion.- C. Proposed Treatment.- 1. Noninvasive Management.- 2. Invasive Methods.- a) Neuroma.- b) Deafferentation Pain.- c) Projected Pain.- D. Results of Treatment.- III. Tumors of the Scar Tissue.- A. Osteoma of the Abdominal Wall.- B. Endometriosis of Scar Tissue.- C. Inflammatory Granuloma.- D. Secondary Malignancy of Scar Tissue.- 7. Closed Trauma of the Abdominal Wall.- I. Hematoma.- II. Localized Rupture.- III. Extensive Subcutaneous Rupture of the Anterior Muscular Wall.- IV. Trauma of the Posterior Abdominal Wall.- V. Abdominointercostal Hernia.- VI. Trauma Caused by Seat Belts.- 8. Defects of the Abdominal Wall.- I. Pathological Defects.- A. Open Trauma.- 1. Burns.- 2. Shotgun Wounds.- 3. Major Dilaceration.- B. Tissue Destruction Due to Infection.- 1. Fournier's Disease.- 2. Subcutaneous Streptococcal Cellulitis.- 3. Gangrene of the Abdominal Wall.- a) Etiology.- (1) Postoperative Gangrene.- (2) Trauma.- (3) Apparently Spontaneous Gangrene.- b) Pathological Findings.- c) Bacteriological Findings.- d) Clinical Features.- e) Prevention and Treatment.- (1) Medical Therapy.- (2) Surgical Treatment.- f) Sequelae.- II. latrogenic Defects.- A. Postoperative Burst Abdomen.- 1. Clinical Features.- a) Free.- b) Fixed.- c) Covered.- 2. Pathogenesis.- a) Emergency Surgery.- b) Site of Incision.- c) Technique of Closure.- d) Postoperative Course.- 3. Treatment.- a) Prevention.- (1) Preoperative.- (2) Peroperative.- (3) Postoperative.- b) Curative.- (1) Free Burst Abdomen.- (2) Delayed Burst Abdomen.- (3) Free Burst Abdomen and Fistula.- (4) Fixed Burst Abdomen and External Fistula.- c) Postoperative Care.- B. Major Incisional Hernia.- 1. Definition.- 2. Introduction.- 3. Natural History.- 4. Physiopathology.- a) Respiratory Disturbances.- (1) Disturbed Respiratory Function.- (2) Effects of Repair on Respiratory Function.- b) Visceral Disturbances.- c) Vascular Disturbances.- d) Muscular Disturbances.- e) Static Disturbances.- f) Surgical Lesions.- g) Medicolegal Considerations.- 5. Anatomicoclinical Subtypes.- a) Midline.- (1) Supraumbilical Incisional Hernia.- (2) Subumbilical Incisional Hernia.- (3) Massive Supra- and Subumbilical Midline Incisional Hernia.- b) Lateral.- (1) Subchondral Incisional Hernia.- (2) Inguinal Incisional Hernia.- (3) Incisional Hernia of the Flank.- 6. Complications.- a) Strangulation.- b) Trophic Ulceration.- c) Secondary Burst Abdomen.- d) Incisional Hernia with Colostomy.- e) Associated Forms.- 7. Principles of Surgical Management.- a) Chronic Incisional Hernia without Sepsis.- (1) Nonprosthetic Repair.- (2) Difficult Management.- b) Septic Incisional Hernia.- 8. Treatment.- a) Preparation.- (1) Role of the Anesthesiologist-Intensive Care Specialist.- (2) Role of the Nursing Staff.- (3) Role of the Surgeon.- b) Surgical Intervention.- (1) Anesthesia.- (2) Exposure and Exploration.- (3) Nonprosthetic Repair.- (4) Prosthetic Repair.- c) Postoperative Care.- d) Treatment of Complications.- 9. Results.- a) Using Prosthetic Material.- (1) Early Postoperative Course.- (2) Long-term Results.- b) Using Nonprosthetic Technique.- c) Emergency Operation.- 10. Comments.- a) Analysis of Results.- Prostheses.- b) Better Selection of Indications.- c) Technical Precautions.- 11. Conclusions.- III. Therapeutic Defects of the Abdominal Wall.- A. Tumors.- 1. Hydatid Cyst.- 2. Desmoid Tumors.- 3. The Dermatofibroma of Darier and Ferrand.- 4. Primary Malignancy.- 5. Secondary Malignancy.- B. Abdominal Wall Repair After Resection.- 1. Under Septic Conditions.- a) Simple Skin Closure.- b) External Cutaneous Reinforcement.- c) Internal Cutaneous Reinforcement with Polyglactine Mesh.- 2. Aseptic Defects.- a) Simple Suturing with Relaxing Incisions.- b) Turndown of Anterior Lamina of Rectus Sheath.- c) Prostheses or Autograft.- d) Myoplasty.- C. Therapeutic Evisceration (Laparostomy).- 1. History of Treatment of Burst Abdomen.- 2. Technique.- 9. Hernia of the Abdominal Wall.- I. Groin Hernias in the Adult.- A. Principles of Treatment.- 1. Some Aspects of Surgical Anatomy of the Inguinal Region.- 2. Hernial Lesions.- 3. Classification of Hernias.- 4. Mechanisms of Inguinal Hernias.- 5. Epidemiology.- 6. Length of Hospital Stay.- 7. Verification of Results and Quality.- 8. Informing the Patient.- B. General Principles of Herniorrhaphy.- 1. The Choice of Approach.- a) The Anterior Inguinal Approach.- b) The Transabdominal Approach.- c) The Preperitoneal Approach.- d) Advantages of the Laparoscopic Approaches.- (1) The Transabdominal Approach.- (2) The Totally Extraperitoneal Approach.- 2. Dissection of the Spermatic Cord.- 3. Management of the Hernial Sac.- 4. Reconstruction of the Inguinal Canal.- a) The "Tissue Repair Technique".- b) "Mesh Repairs".- 5. Anesthesia in Hernia Surgery.- a) Anesthesia and Laparoscopic Herniorrhaphies.- b) Local Anesthesia Performed by the Surgeon.- C. Classical Herniorrhaphy by the Inguinal Approach.- 1. The Marcy Operation (1871).- 2. The Bassini Operation (1887).- a) The Houdard Procedure.- b) The Chevrel Procedure.- 3. The Shouldice Operation.- a) Evolution of the Technique.- b) Weight Control.- c) Local Anesthesia.- d) Surgery.- (1) Dissection.- (2) Reconstruction.- e) Follow-up.- f) Complications.- (1) Infections.- (2) Hematomas.- (3) Hydroceles.- (4) Testicular Atrophy.- g) Activity.- h) Cost.- i) Conclusion.- 4. The McVay Operation.- 5. The Nyhus Operation.- 6. General Observations on Suture Repairs.- D. Tissue Transfers via the Inguinal Route.- 1. The Berger-Orr Procedure.- 2. The Hindmarsh Procedure.- 3. Transposition of the Spermatic Cord.- 4. Transfer of Fascia Lata or Skin.- 5. General Criticism of Tissue Transfer.- E. Techniques Involving the Use of Prosthetic Material.- 1. Prosthetic Repair by the Inguinal Route.- a) The Rives Operation.- (1) Preparation of the Prosthesis.- (2) Critical Comments.- b) The Lichtenstein Open Tension-free Hernioplasty.- (1) Techniques of Anesthesia.- (2) Technique of Operation.- (3) Outcome Measures.- (4) Prevention of Recurrences.- (5) Isolated Femoral Hernia and Recurrent Inguinal Hernia: Concept of the Plug Repair.- (6) Discussion.- c) The Gilbert Operation.- (1) Technique.- (2) Results.- (3) Complications.- (4) Conclusion.- d) The Plugs.- (1) A Short History of the Concept.- (2) Technique.- (3) Personal Experience.- (4) Discussion.- (5) Conclusion.- 2. Prosthetic Repair via the Open Abdomen.- a) The Rives Operation: Unilateral Prosthesis by the Preperitoneal Route.- b) The Stoppa Operation.- c) The Wantz operation.- 3. Prosthetic Repair via the Laparoscopic Route.- a) The Extraperitoneal Route (TEP).- (1) Technique.- (2) Variations.- (3) Complications.- (4) Indications.- b) The Trans-Abdominal Preperitoneal Route (TAPP).- (1) Technique.- (2) Special Cases.- (3) Advantages and Disadvantages.- (4) Results.- (5) Personal Series.- (6) Discussion.- (7) Conclusion.- F. Intraoperative Complications of the Classical Surgical Repairs.- 1. Hemorrhage.- 2. Spermatic Cord Lesions.- 3. Nerve Injury.- 4. Injury to the Vas Deferens.- 5. Bladder Injury.- 6. Injury to an Abdominal Organ.- G. The Postoperative Period.- 1. Postoperative Analgesia.- 2. Prevention of Thromboembolism.- 3. Antibiotics.- 4. Ambulation and Length of Hospital Stay.- 5. Resumption of Activities and Work.- 6. Early Postoperative Complications.- a) Hematomas.- b) Wound Infection.- c) Hydrocele.- d) Ischemic Orchitis.- e) Urinary Complications.- f) Thromboembolism.- g) Respiratory Complications.- h) Gastrointestinal Complications.- i) General Complications and Mortality.- H. Late complications.- 1. Sequelae.- a) Testicular Atrophy.- b) Chronic Postoperative Pain.- c) Painful Ejaculation.- d) Migration of the Prosthesis.- e) Late Infectious Complications (fistulae).- 2. Problems with Re-operation Following Retromuscular Prosthetic Repair.- a) Surgery for Benign Prostatic Hypertrophy.- b) Surgery for Prostatic or Vesical Malignancy.- c) Surgery of the External Iliac Vessels.- I. Special Problems.- 1. Irreducibility.- 2. Bruising around the Hernial Site.- 3. Problems with Trusses.- 4. Strangulation.- 5. Femoral Hernias.- a) An Umbrella for Femoral Hernias.- (1) The Source of the Problem.- (2) The Femoral Umbrella.- (3) Results.- (4) Discussion.- (5) Conclusion.- b) Strangulated Femoral Hernia.- 6. Richter's Hernia.- 7. Bulky Hernias.- 8. Adherent Hernias. Sliding Hernias.- 9. Bilateral Hernias.- 10. Hernial Lipomas.- 11. Associated Lesions.- a) Patent Processus Vaginalis.- b) Hernias with Ectopic Testis.- c) Hernia and Hydrocele.- d) Hernia with Varicocele.- e) Hernias with Malformation of the Processus Vaginalis.- 12. Inguinal Hernias in Women.- 13. Hernias in the Elderly.- 14. "Incidental" Hernias.- 15. Recurrent Hernias.- a) Frequency.- b) Delay in Presentation.- c) Anatomical Types.- d) Mechanism.- e) Treatment.- f) Results of Repair of Recurrent Hernias.- II. Other Hernias.- A. Epigastric Hernias.- 1. Frequency.- 2. Pathological Anatomy.- 3. Clinical Picture.- 4. Treatment.- 5. Results.- B. Diastasis of the Rectus Muscles.- C. Spigelian Hernias.- 1. Frequency.- 2. Pathological Anatomy.- 3. Clinical Picture.- D. Lumbar Hernias.- 1. Pathological Anatomy.- 2. Clinical Picture.- 3. Treatment.- E. Pelvic Hernias.- 1. Obturator Hernias.- a) Frequency.- b) Clinical Picture.- c) Treatment.- (1) Route of Access.- (2) Results.- 2. Sciatic Hernias.- a) Frequency.- b) Pathological Anatomy.- c) Clinical Picture.- d) Treatment.- 3. Perineal Hernias.- a) Clinical Picture.- b) Treatment.- 10. Pathology of the Umbilicus.- I. Umbilical Hernia.- A. Pathological Anatomy.- B. Anatomicoclinical Forms.- 1. Small Hernia.- 2. Large Hernia.- 3. In Patients with Cirrhosis.- II. Tumors of the Umbilicus.- A. Primary Tumors.- B. Secondary Tumors.- C. False Tumors.- III. Fistula and Suppurative Lesions.- A. Fistula.- 1. Urinary Fistula.- 2. Fistula of the Urachus.- 3. Fistula of the Digestive Tract.- 4. Treatment.- B. Suppurative Lesions.- 1. Secondary Suppuration.- 2. Primary Suppuration.- IV. Conclusion.- 11. Abdominoplasty.- I. Consultation Prior to Abdominoplasty.- II. Therapy.- A. Low Transverse Incision.- B. Combined Low Transverse and Vertical Incision.- C. Indications, Resulting Scar, and Complications.- 1. Hematoma.- 2. Lymph Effusion.- 3. Cutaneous Necrosis.- 4. Thromboembolism.- D. Special Cases.- 1. Localized or Minor Cases.- 2. Major Cases or Those Accompanying Old Scars.- 3. Associated Lipolysis.- 4. Endoscopic Correction.- 5. Umbilicoplasty.- 12. The Abdominal Wall in Infants and Children.- I. Omphalocele, Cord Hernia, Laparoschisis.- A. Incidence and Etiological Factors.- B. Anatomicoclinical Aspects.- 1. Omphaloceles.- 2. Cord Hernias.- 3. Laparoschisis.- C. Embryological Facts.- D. Diagnosis.- E. Management at the Time of Birth.- F. Treatment.- 1. Primary Closure.- 2. Progressive Replacement.- 3. Deferred Reduction.- 4. Conservative Treatment.- 5. Special Problems Resulting from GI Tract Abnormalities.- 6. Postoperative Management.- G. Results.- II. Pathology of the Umbilicus Due to Defective Involution of the Omphalomesenteric Duct and Urachus.- A. Defective Involution of the Omphalomesenteric Duct.- 1. Total Persistence of the Omphalomesenteric Duct.- 2. Entero-umbilical Fistula.- 3. Umbilical Remnants.- B. Defective Involution of the Urachus.- 1. Urachal Fistula.- 2. Urachal Sinus.- 3. Urachal Cyst.- III. Groin Hernias in Children.- A. The Processus Vaginalis.- B. Incidence.- C. Diagnosis.- D. Treatment.- 1. Uncomplicated Hernias.- 2. Obstructed and Strangulated Hernia.- 3. Inguinal Hernia with Undescended Testis.- 4. Inguinal Hernia in Girls.- E. Particular Problems.- 1. Hernial Appendix.- 2. Meckel's Diverticulum.- 3. Splenogonadal Fusion and Aberrant Splenic Nodules.- 4. Adrenal Nodules.- 5. Anomalies of Testicle and Vas Deferens.- 6. Mullerian Structures in Boys.- 7. Herniation of the Bladder.- 8. Cystic Hygroma.- 9. Hernias and General Congenital Abnormalities.- F. Direct Inguinal Hernias.- G. Recurrences.- H. Femoral Hernia.- IV. Umbilical Hernias in Children.- A. Incidence.- B. Diagnosis.- C. Treatment.- V. Epigastric Hernias in Children.- VI. Divarication of the Recti in Children.- VII. Spigelian Hernia in Children.