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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