Abdominal PainAbdominal Mass - PowerPoint PPT Presentation
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Title:
Abdominal PainAbdominal Mass
Description:
Presents to ER with one day history of sudden, worsening abdominal pain ... Enlarges over time leading to pain, bowel obstruction, incarceration, and strangulation ... – PowerPoint PPT presentation
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Title: Abdominal PainAbdominal Mass
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Abdominal Pain/Abdominal Mass
- Melissa L. Hughes
- Scott Q. Nguyen, M.D.
- Celia M. Divino, M.D.
- Department of Surgery
- Mount Sinai School of Medicine
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HPI Mrs.Masseo
- Mrs. Masseo is a 63-year-old female with PMH of
HTN, DM, s/p laparotomy for peptic ulcer disease
seven years ago - Presents to ER with one day history of sudden,
worsening abdominal pain associated with nausea,
two episodes of vomiting, and abdominal
distension
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- What other information would you want regarding
this patients history?
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Other Pertinent HPI
- Patient had noticed a bulging from her mid
abdomen beneath the surgical scar for the past
several months. It was not initially painful,
became larger when she coughed, and would go away
when she was lying down - After an acute coughing episode the morning prior
to admission, patient reported that she suddenly
experienced severe pain in her mid abdomen that
was constant and accompanied by an increase in
size of the midline bulge which did not go away
when she tried to lie down - No flatus or bowel movement over the past day,
several episodes of vomiting, and subjective
fevers
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Other Pertinent History
- PMH Poorly controlled HTN and DM for the past 20
years - PSH Appendectomy at age 35, laparotomy 7 years
ago for PUD - Meds lisinopril, insulin, nexium, aspirin
- Allergies NKDA
- Social history 1.5 packs of cigarettes a day for
the past 40 years
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- What would you look for on physical exam?
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Physical Exam
- Ill-appearing, obese woman in severe pain
- BP 100/60 HR 115 Temp 38.2 C RR 24
- HEENT oral mucosa dry
- Heart tachycardic, regular rhythm
- Lungs clear to auscultation bilaterally
- Abdomen obese abdomen, healed midline
laparotomy and RLQ scars, hypoactive bowel
sounds, moderate distension, firm, tender
softball size mass at midline scar with erythema
of the overlying skin. No rebound or guarding in
remaining abdomen - Guaiac positive stool
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- What is your differential diagnosis?
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Differential Diagnosis
- Incarcerated ventral hernia
- Small/large bowel obstruction- secondary to
adhesions, volvulus, neoplasm - Abdominal wall tumor
- Abdominal wall abscess
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- What labs would you order?
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Lab results, Mrs. Masseo
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134
94
40
15
350
190
3.3
20
1.7
30.1
n 89 LFTs, amylase, lipase,
and coags- WNL
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Lab Findings
- Pre-renal azotemia secondary to dehydration
- Leukocytosis from infection/inflammatory process
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- What imaging would you like to obtain?
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Obstructive Series
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Obstructive Series
Describe the X-ray findings
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Xray Interpretation
- No free air noted on CXR
- No significant small bowel dilatation
- Air in right colon
- No small bowel obstruction
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If this patient had bowel obstruction secondary
to an incarcerated loop of small bowel in the
ventral hernia, then why are there no signs of
small bowel obstruction on Xray?Is there
another study which may help?
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CT Scan Mrs. Masseo
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CT Interpretation
- Transverse colon incarcerated in ventral
abdominal wall hernia - Soft tissue stranding in subcutaneous fat around
incarcerated hernia - Absence of enteric contrast past area of
incarceration with collapse of left colon
consistent with complete large bowel obstruction
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- What would be your next step in management?
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Hospital Course
- Immediate resuscitation with IV fluids, foley
catheter, NG tube decompression and pre-op
antibiotics - Patient taken to the OR for incarcerated hernia
with suspected strangulated bowel - Exploratory laparotomy performed using previous
midline incision - Found to have ischemic loop of transverse colon
twisted upon itself, herniating through a 4cm
abdominal wall defect - Segment of ischemic bowel was resected and
primary anastomosis performed - Hernia repaired primarily, skin was left open
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Hospital Course
- Patient did well post-operatively without
complications - POD 4 regained bowel function
- POD 6 tolerated normal diet
- POD7 discharged home
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- What is the problem with repairing this patients
hernia primarily? Would you want to use mesh in
this situation?
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Primary repair of Ventral (Incisional) Hernia
- Recurrence of a ventral hernia is a common
problem in primary suture repair, whereas repair
with prosthetic mesh often has lower recurrence
rates - However, in a patient with strangulated, ischemic
bowel who undergoes a bowel resection, inserting
mesh into a contaminated field increases risk of
infection of the mesh and ultimate need for
reoperation and removal
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Follow-up
- Patient seen at follow-up appointment 6 months
later and was found to have another reducible
hernia through the same 4cm abdominal wall defect - Patient denied any abdominal pain, distension,
nausea, vomiting, or fevers
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- What would you do next to help this patient?
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- Discuss treatment options for repair of recurrent
incisional hernias - Discuss pre-operative preparation
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Follow-up
- Patient taken back to the OR for elective ventral
hernia repair - Open hernia repair performed using non-absorbable
mesh in an under-lay fashion - Patient continues to do well two years after
elective repair without any signs or symptoms of
recurrence
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Incisional Hernia Discussion
- Hernias that occur at a prior abdominal incision
site (includes post laparotomy hernias,
parastomal hernias, and trocar site hernias) - Incisional hernias reported in up to 20 of
patients undergoing laparotomy with modern rates
ranging from 2-11 - Approximately 100,000 ventral incisional hernia
repairs performed each year in U.S. - Most present within 12 months post-laparotomy
although as many as 1/3 may present 5-10 years
later
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- What are the risk factors for developing an
incisional hernia?
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Risk Factors
- Patient-related factors advanced age,
malnutrition, diabetes mellitus, cigarette
smoking, corticosteroids, conditions that
increase intra-abdominal pressure like obesity
ascites, or chronic cough - Surgery-related factors wound or intraabdominal
infection, closure of abdomen under tension, type
and location of incision (vertical midline
incision more prone to incisional hernia than
transverse), lack of mesh overlap at hernia edges
(bridge technique)
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Clinical Manifestations and Diagnosis
- Bulge in abdominal wall at or near surgical scar
- Discomfort aggravated by coughing or straining
- Enlarges over time leading to pain, bowel
obstruction, incarceration, and strangulation - In large hernias, the skin may present with
ischemic or pressure necrosis resulting in
ulceration - Usually easy to identify on exam, with palpable
edges of fascial defect - In obese patients with suspected incisional
hernias the surgeon should have a low threshold
for obtaining a CT abdomen as the clinical exam
is very unreliable
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Treatment
- Treatment includes two general types of operative
repair primary suture repair and prosthetic mesh
repair - Recurrence rates for non-prosthetic repair can be
as high as 50 or more, whereas mesh repair is
associated with significantly lower recurrence
rates
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Primary Repair
- Usually performed for hernia defects less than 4
cm in diameter, with strong, viable surrounding
tissue using an interrupted layer of
nonabsorbable sutures - Some studies have suggested that even these
small hernias may have a substantially lower
recurrence rate after mesh repair - Separation of components is a technique that
utilizes the bodys own tissues for hernia
repair, avoids the use of a foreign body, and in
experienced hands may have very good results
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Prosthetic Repair
- For large hernias, or hernias associated with
multiple small defects, mesh should be placed by
open or laparoscopic approach - Mesh provides tension-free repair by avoiding the
recreation of tension by fascial apposition. In
large hernias with loss of domain , fascial
apposition may not even be possible. - Much improved recurrence rates over primary repair
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Prosthetic Repair
- Many different prosthetic materials available
today for hernia repair but limited evidence and
comparative studies exist - Bioabsorbable meshes have become popular and may
be used in an infected field but should not be
regarded as permanent hernia repair as high rates
of recurrence/ dilatation have recently been
described - Many techniques for mesh placement (ex)
Rives-Stoppa repair where mesh is placed in
retrorectus space, laparoscopic repair with mesh
placement intraabdominally behind the rectus and
peritoneum, open in-lay, on-lay and under-lay
mesh repairs. - Technique may be paramount in recurrence rates
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Complications
- Recurrence As high as 30-50 in primary suture
repair, 5-35 in open mesh repair, and 0-11 in
laparoscopic mesh repair - Wound infections are more common after open
repair compared to laparoscopic - Mesh infection often necessitates removal of mesh
but can occasionally be treated with IV
antibiotics and local wound care - Erosion of mesh into bowel with development of
enterocutaneous fistulas - Bowel obstruction/ileus
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QUESTIONS ??????
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References
- Feldman LS, et al. Laparoscopic Hernia Repair.
ACS - Surgery Principles and Practice. Chapter
5, Section - 28. 2003
- Fitzgibbons RF, et al. Open Hernia Repair. ACS
- Surgery Principles and Practice. Chapter
5, Section - 27. 2003
- Townsend CM. Sabiston Textbook of Surgery. 17th
- edition
- Zinner, MJ, et al. Postoperative Ventral Wall
- (Incisional) Hernia. Maingots Abdominal
Operations. - Chapter 5. Hernias. 11th edition
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- Acknowledgment
- The preceding educational materials were made
available through theASSOCIATION FOR SURGICAL
EDUCATION - In order to improve our educational materials
wewelcome your comments/ suggestions at - feedbackPPTM_at_surgicaleducation.com
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