CASE PRESENTATION AND SHARING OF INFORMATION ON INCISIONAL HERNIA

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CASE PRESENTATION AND SHARING OF INFORMATION ON
INCISIONAL HERNIA

• by
• Michael Angelo L. Suñaz, M.D.
• Department of Surgery
• Ospital ng Maynila Medical Center

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R.C, 58/M TONDO, MANILA
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• CHIEF COMPLAINT BULGING ABDOMINAL MASS

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HISTORY OF PRESENT ILLNESS

• 2 yrs PTA ? Px underwent E
• Exploratory
  Laparotomy,
• duodenorrhapy, omental
• patching for a
  Perforated
• PUD.

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HISTORY OF PRESENT ILLNESS

• 22 months PTA ?noted bulging abdominal
• mass, about
  the size of the
• patients
  fist, most noticeable
• during
  straining or prolonged
• standing and
  reduced
• spontaneously
  when the patient
• assumed a
  recumbent position.
• (-) episode of vomiting
• (-) changes in BM

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HISTORY OF PRESENT ILLNESS

• Gradual increase in the size of the abdominal
  mass prompted consultation and subsequent
  admission at the OMMC

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• PAST MEDICAL Hx
• s/p E Ex-Lap, duodenorrhaphy, omental patch
  for Perforated Peptic Ulcer Disease OMMC July
  2004
• No Hypertension
• No DM
• FAMILY Hx
• No heredofamilial disease noted

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• PERSONAL/SOCIAL Hx
• smoker, 20 pack-years, stopped last 2004
• occasional alcoholic beverage drinker

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PHYSICAL EXAMINATION

• BP 120/80 CR89 RR 20 T36.5
• HEENT pink palpebral cojunctiva,anicteric
  sclera, No NAD, No CLAD, No TPC
• C/L SCE, no retractions, clear BS
• HEART adynamic precordium, NRRR, no murmur

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• ABDOMEN Flabby, NABS, soft, non-tender
• () healed midline incision
• () mass, soft, non-tender, reducible, around the
  umbilicus with fascial defect approx 8 x 8 cms
  around the umbilicus
• () mass, soft, non-tender, reducible, 6 cms
  above the umbilicus with fascial defect approx
  2x2 cms.

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• EXTREMITIES full equal pulses, No edema

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SALIENT FEATURES

• 58 y/o, M
• 2-yr History of bulging abdominal mass, reducible
• Fascial defect approx 8 x 8 cms and 2 x 2 cms
• History of previous operation

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On and off bulge at the level of the abdominal
wall
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On and off bulge at the level of the abdominal
wall
Abdominal wall hernia
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On and off bulge at the level of the abdominal
wall
Abdominal wall hernia
History of operation bulge at incisional site
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On and off bulge at the level of the abdominal
wall
Abdominal wall hernia
History of operation bulge at incisional site
Incisional hernia
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On and off bulge at the level of the abdominal
wall
Abdominal wall hernia
History of operation bulge at incisional site
Incisional hernia
Not reducible
reducible
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On and off bulge at the level of the abdominal
wall
Abdominal wall hernia
History of operation bulge at incisional site
Incisional hernia
Not reducible
reducible
Defect on 1 site
Defect on 2 or more sites
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On and off bulge at the level of the abdominal
wall
Abdominal wall hernia
History of operation bulge at incisional site
Incisional hernia
Not reducible
reducible
Defect on 1 site
Defect on 2 or more sites
strangulated
Not strangulated
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Clinical Diagnosis
Diagnosis Certainty Treatment
Incisional Hernia without obstruction or gangrene 99 Surgical
Incisional Hernia with obstruction or gangrene 1 Surgical
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BASIS

• Patient with history of
• on and off bulging mass on incision site,
• s/p E Exploratory Laparotomy without any
• vomiting or BM changes

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Do I need a para-clinical diagnostic procedure?

• NO

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Pretreatment Diagnosis
Diagnosis Certainty Treatment
Incisional Hernia without obstruction or gangrene 99 Surgical
Incisional Hernia with obstruction or gangrene 1 Surgical
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TREATMENT

• PRETREATMENT DIAGNOSIS
• Incisional Hernia without obstruction or gangrene
  s/p E Ex-Lap July 2004

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TREATMENT

• GOALS OF TREATMENT
• - reduce hernial content
• - repair the fascial defect
• - prevent recurrence of incisional hernia
• after the repair

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Non-surgical (binders, corsets) gtMay be used pre-operatively to TEMPORARILY reduce large necked hernias of high risk patients gtno repair of fascial defect Injury to skin or bowel due to the pressure may mask signs of incarceration or strangulation P500-1000 available
Surgical gtreduction of hernial content gtrepair of fascial defect Up to 50 recurrence rate with 5 prosthesis related infection rate OR cost 6,000-40,000 available

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Open Surgery gtreduction of hernial contents gtrepair of hernial defect gtWider incision gtmore invasive gtlonger recovery time OR cost P6000 (if with prosthesis) Readily available
Laparoscopic Surgery gtreduction of hernial contents gtrepair of hernial defect gtsmaller incision gtless invasive gtshorter recovery time OR cost P40000 Not readily available

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Simple non-prosthesis repair gtreduction of hernial contents gtrepair of hernial defect 25-55 recurrence rate1 OR cost available
Incisional herniorrhaphy with mesh gtreduction of hernial contents gtrepair of hernial defect 1-20 recurrence rate Prosthesis-related infection (5) 2 OR cost P6,000 available

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Onlay prosthetic repair gtreduction of hernial contents gtrepair of hernial defect gtRecurrence rate of 2.5 13.3 gtSubprosthetic Hernia gtWound healing complications due to direct contact of prosthesis with environment during wound revision OR cost P6000 available
Sublay prosthetic repair gtreduction of hernial contents gtrepair of hernial defect Recurrence rate of 1 - 20 OR cost P6000 available

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TREATMENT OF CHOICE

SUBLAY PROSTHESIS REPAIR
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PREOPERATIVE PREPARATION

• Informed consent
• Psychosocial support
• Optimize patients health
• Screen for any condition that will interfere with
  treatment
• Prepare materials

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OPERATIVE TECHNIQUE

• Patient supine under CLEA
• Asepsis/Antisepsis
• Sterile drapes
• Excision of scarred incision skin
• Subfascial flap dissection separating rectus from
  peritoneum/hernial sac
• Hernial sac opened

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OPERATIVE TECHNIQUE cont..

• Inspection of intraabdominal organs for gut
  adhesions and additional fascial defects
• Silk suture laid on peritoneum for mesh anchoring
• Interrupted Silk 2-0 sutures approximating small
  superior fascial defect
• Excess peritoneum trimmed
• Closure of peritoneum with chromic 3-0 simple
  continuous

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OPERATIVE TECHNIQUE cont..

• Mesh laid over the area of larger defect
• Anchoring sutures tied
• Closure of fascia with simple continuous suture,
  Vicryl-0
• Hemostasis
• Running continuous with Vicryl 2-0 subcutaneous
• Subcuticular Vicryl 4-0
• Correct sponge, instrument and needle count
• Dry Sterile Dressing

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OPERATIVE TECHNIQUE
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OPERATIVE FINDINGS

• 7 cms fascial defect from umbilicus down and 1 cm
  above
• Small fascial defect approx 1x1 cms, 6 cms
  superior to the umbilicus, left of the midline
• No incarcerated bowel noted

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OPERATION DONE

• Incisional Herniorrhaphy with subfascial
  prosthesis

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POST-OP CARE

• Sufficient analgesia
• Nutrition
• Wound care
• Monitoring of complications and treat as
  indicated
• Advice on home care of wound

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POST-OP CARE

• Advice on ff-up plans
• Avoid straining
• Avoid lifting heavy objects/ learn the proper
  mechanics of lifting
• High fiber diet
• Quit smoking
• Maintain a healthy weight

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SHARING OF INFORMATION
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INCISIONAL HERNIA

• occur as a complication of previous surgery
• Causes
• 1. poor surgical technique
• 2. rough handling of tissues
• 3. use of rapidly degraded
• absorbable suture
  materials
• 4. closure of the abdomen under
• tension,
• 5. infection

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• 6. Male sex
• 7. advanced age
• 8. morbid obesity
  9.abdominal distention
• 10. cigarette smoking
• 11. pulmonary disease
• 12. hypoalbuminemia

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• The incidence of incisional hernia was
  significantly lower when nonabsorbable sutures
  were used in a continuous closure however,

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• the incidence of suture sinus formation (9) and
  that of wound pain were significantly higher

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• The best definition
• any abdominal wall gap, with or without a
  bulge, that is perceptible on clinical
  examination or imaging by 1 year after the index
  operation.

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• Incidence 3 20 (double if the index operation
  is associated with infection)

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• Risk midline - 10.5
• transverse - 7.5,
• paramedian - 2.5

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• Early evisceration is commonly seen among males.

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• Incarceration and strangulation occur with
  significant frequency, and recurrence rates after
  operative repair approach 50.

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Classification of incisional hernias

• I. According to localization (modified Chevrel)
  
• Vertical
• 1.1. Midline above or below umbilicus
• 1.2. Midline including umbilicus right or left
• 1.3. Paramedian right or left
• Transversal
• 2.1. Above or below umbilicus right or left
• 2.2. Crossed midline or not

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Classification of incisional hernias

• Oblique
• 3.1. Above or below umbilicus right or left
• Combined (midline oblique midline
  parastomal etc)

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Classification of incisional hernias

• II. According to size
• Small (lt5 cm in width or length)
• Medium (5-10 cm in width or length)
• Large (gt10 cm in width or length)

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Classification of incisional hernias

• III. According to recurrence
• Primary incisional hernia
• Recurrence of an incisional hernia (1., 2., 3.,
  etc. with type of hernioplasty adaptation,
  Mayo-duplication, prosthetic implantation,
  autodermal etc.)

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Classification of incisional hernias

• IV. According to the situation at the hernia
  gate
• Reducible with or without obstruction
• Irreducible with or without obstruction

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Classification of incisional hernias

• V. According to symptoms
• Asymptomatic
• Symptomatic

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Operative Technique

• I. Simple Non-Prosthesis Repair
• II. Posthesis Repair
• a. Onlay Prosthetic Repair
• b. Prosthetic Bridging Repair
• c. Combined Fascial and Mesh
• Closure
• d. Sublay Prosthetic Repair

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Simple Non-Prosthesis Repair

• recurrence rate ranges from 25 to 55
• According to the experts' recommendation, the
  fascia-duplication should only be used for small
  incisional hernias (3 cm or less) and if the
  reconstruction of the repair is oriented
  horizontally

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• monofile non-resorbable material - U-suture by
  Mayo-duplication or running suture with a
  suturewound length ratio of 41.

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Prefascial (Onlay) Prosthetic Implantation
(Chevrel-technique)

• The recurrence rates indicated in the literature
  vary between 2.5 and 13.3
• Authors using this technique estimate the amount
  of wound healing complications after this
  operation to range between 4 and 26 and
  estimate the rate of prosthesis removals between
  0 and 2.5

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Prefascial (Onlay) Prosthetic Implantation
(Chevrel-technique)

• The main disadvantage of the onlay technique is
  the direct contact of the prosthesis (partly or
  completely) with the environment during the wound
  revision, which can cause wound healing
  complications.
• "subprosthetic hernia"

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Subfascial Prosthetic Repair (Sublay Technique)

• retromuscular approach
• placement of a large prosthesis in the space
  between the abdominal muscles and the peritoneum.
• To date, no controlled study has been published
  that has tested the sublay technique versus the
  onlay technique

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Subfascial Prosthetic Repair (Sublay Technique)

• Recurrence rate 1 20

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Subfascial Prosthetic Repair (Sublay Technique)

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Choice of Prosthesis

• Type I. - Totally macroporous prostheses (pores
  larger than 75 µm)
• Marlex
• Monofilament polypropylene
• Prolene
• Double filament polypropylene
• Atrium
• Monofilament polypropylene

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Choice of Prosthesis

• Type II. - Totally microporous prostheses (pores
  less than 10 µm)
• Gore-Tex
• Expanded PTFE

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Choice of Prosthesis

• Type III - Mix-prostheses (macroporous with
  multifilamentous or microporous components)
• Teflon
• PTFE mesh
• Mersilene
• Braided Dacron mesh
• Surgipro
• Braided polypropylene mesh
• MicroMesh
• Perforated PTFE patch

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Autodermal hernioplasty

• According to the literature, the recurrence rates
  of the autodermal hernioplastic and the
  prosthetic strengthening are comparable

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Laparoscopic Hernia Repair

• may be considered for any ventral hernia in which
  mesh will be used for the repair.
• Contraindication suspected strangulated bowel or
  loss of domain

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Poor results of Incisional Hernia Repair

• 1. preexisting comorbid conditions
• 2. cancer-related debilitation
• 3. morbid obesity
• 4. use of steroids
• 5. chemotherapy

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MCQ

• 1. Which of the following is a contraindication
  for laparoscopic hernia repair?
• a. patients with suspected strangulated bowel
• b. Swiss cheese hernia
• c. defects in close proximity to the
  bony
• margins of the abdomen
• d. dense adhesions

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MCQ

• 1. Which of the following is a contraindication
  for laparoscopic hernia repair?
• a. patients with suspected strangulated
• bowel
• b. Swiss cheese hernia
• c. defects in close proximity to the
  bony
• margins of the abdomen
• d. dense adhesions

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• 2. If an incisional hernia has a fascial gap of
  10 x 6 cms, it is considered to be?
• a. Small
• b. Medium
• c. Large
• d. Not enough data to classify

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• 2. If an incisional hernia has a fascial gap of
  10 x 6 cms, it is considered to be?
• a. Small
• b. Medium
• c. Large
• d. Not enough data to classify

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• 3. Which of the following is not considered to
  be a predisposing condition for the development
  of incisional hernia?
• a. emphysema
• b. deep surgical site infection
• c. BMI of 24
• d. Poor surgical technique

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• 3. Which of the following is not considered to
  be a predisposing condition for the development
  of incisional hernia?
• a. emphysema
• b. deep surgical site infection
• c. BMI of 24
• d. Poor surgical technique

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MCR

• A 1, 2, and 3 are correct
• B 1 and 3 are correct
• C 2 and 4 are correct
• D only 4 is correct
• E none are correct

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MCR

• I. Which of the following is true of simple
  non-prosthetic repair of incisional hernia?
• 1. recurrence rate ranges from 25 to 55.
• 2. If there is a solitary defect 3 cm or less in
  diameter,
• primary closure with absorbable
  suture material is
• appropriate.
• 3. Less time consuming and assoc with less
• complication
• 4. Because of the high recurrence rates, the
  simple
• fascia-duplication can no longer be
  regarded as the
• "gold standard"

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MCR

• I. Which of the following is true of simple
  non-prosthetic repair of incisional hernia?
• 1. recurrence rate ranges from 25 to 55.
• 2. If there is a solitary defect 3 cm or less in
  
• diameter, primary closure with
  absorbable
• suture material is appropriate.
• 3. Less time consuming and assoc with less
• complication
• 4. Because of the high recurrence rates, the
• simple fascia-duplication can no
  longer be
• regarded as the "gold standard"

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• II. Which of the ff is/are true about prosthesis
  repair?
• 1. Prefascial prosthesis Implantation
  subprosthesis hernia
• 2. Sublay Technique large prosthesis in the
  space
• between the abdominal muscles
  and the peritoneum.
• 3. Combined Fascial and Mesh Closure posterior
  fascia
• is closed primarily, The anterior
  fascia is then bridged
• with a prosthesis
• 4. Sublay Technique not suited for
  swiss-cheese hernia

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• II. Which of the ff is/are true about prosthesis
  repair?
• 1. Prefascial prosthesis Implantation
  subprosthesis
• hernia
• 2. Sublay Technique large prosthesis in the
  space
• between the abdominal muscles
  and the
• peritoneum.
• 3. Combined Fascial and Mesh Closure
  posterior
• fascia is closed primarily, The
  anterior fascia is
• then bridged with a prosthesis
• 4. Sublay Technique not suited for
  swiss-cheese hernia

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• THANK YOU!!!

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References

• Fitzgibobns, et al open hernia repair, Section 5
  Chapter 27 ACS Principles and Practice 2003