Bohomolets Surgery 4th year Lecture #2


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By. Prof Kucher M. from Faculty Surgery Department #1

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Bohomolets Surgery 4th year Lecture #2

  1. 1. LECTURE 2 ABDOMINAL WALL HERNIAS National O. Bogomolets Medical University Faculty Surgery Department N1 Kyiv 2007 Prof. Kucher M.
  2. 2. A h ernia is a hole in the abdominal wall. This hole allows the protrusion of a structure that is supposed to be within the abdomen. The structure that protrudes can be some fat, a loop of intestine, the appendix, an ovary, or part of the bladder. You can think of a hernia like an inner tube of a tire that is protruding out of the outer tread which is worn out. Hernias can occur in men and women of all ages and in children. Some hernias are present at birth. Others develop slowly over a period of months or years.
  3. 4. INCIDENCE No peritoneum sac - no hernia:
  4. 5. Abdominal wall (ventral) hernias Inguinal hernias are in the groin area. They are most common in men, primarily because of the unsupported space left in the groin after the testicles descend into the scrotum
  5. 6. Abdominal wall (ventral) hernias femoral hernias occur at the top of the thigh in the space through which the femoral artery, vein, and nerve pass into the thigh. These hernias occur most often in women
  6. 7. Abdominal wall (ventral) hernias Umbilical hernias occur in the umbilicus (belly button). They are usually congenital hernias (present since birth)
  7. 8. Abdominal wall (ventral) hernias Incisional hernias occur at the site of previous abdominal surgery
  8. 9. Inferior lumbar hernia of Petit Superior lumbar hernia of Grynfellt-Lesshaft
  9. 10. The anterior perspecrive
  10. 11. The posterior perspecrive
  12. 13. Congenital inguinal hernia Inguinal hernia: the processus vaginalis has remained open allowing abdominal contents (fluid and loops of bowel) to enter into the scrotum Noncommunicating hydrocele Normal scrotum
  13. 14. Can I get above it? hydrocele Congenital hernia
  14. 15. the hernia sac exits through the internal inguinal ring and takes an oblique path the hernia sac exits through the external inguinal ring directly Inguinal hernias can be indirect or direct:
  15. 16. A sliding hernia is an indirect hernia where the posterior wall of the sac is formed by large bowel (ascending colon on the right, sigmoid/descending colon on the left) or bladder
  16. 17. Why do hernias develop? Familial predisposition: connective tissue disorders (altering collagen formation) Hernias commonly develop in an area of weakness including natural spaces and thin tissue, such as the internal inguinal ring and the floor of the inguinal canal. Hernias may develop at these sites or other areas due to aging, injury, an old incision, or a weakness present at birth. Another important factor in the development of hernias is an increase in the intra-abdominal pressure . This could be secondary to chronic constipation and prolonged straining, chronic persistent coughing, lifting heavy objects, pregnancy, obesity, or chronic liver disease.
  17. 18. Symptoms & signs Protruding bulge Pain Discomfort Weakness symptoms of Inguinal hernia: Groin lump Groin pain Intestinal blockage reducible swelling ritual of patient cough
  18. 19. Physical examination
  19. 20. DIFFERENTIALS <ul><li>Epididymitis </li></ul><ul><li>Hidradenitis Suppurativa </li></ul><ul><li>Hydrocele </li></ul><ul><li>Lymphogranuloma Venereum </li></ul><ul><li>Testicular Torsion </li></ul>Groin abscess Hematoma Lipoma Lymphadenitis Pseudoaneurysm Spermatocele Tumor Undescended or retracted testes Varicocele
  20. 21. US & Radiology
  21. 22. <ul><li>With more than 20 million hernia repairs occurring annually worldwide, hernia repair is indeed the most common general surgical operation. </li></ul>
  22. 23. Inguinal hernia repairs <ul><li>Open Nonprosthetic (Tension repair) </li></ul><ul><li>Open Prosthetic (Tension-free) </li></ul><ul><li>Laparoscopic TAPP or TEP (Tension-free) </li></ul>
  23. 24. Open Nonprosthetic: Bassini
  24. 25. Open Nonprosthetic: Shouldice
  25. 26. Open Prosthetic : Lichtenstein
  26. 27. М. Кучер Laparoscopic ТАРР
  27. 28. М. Кучер ТАРР
  28. 29. М. Кучер ТАРР
  29. 30. М. Кучер ТАРР
  30. 31. М. Кучер ТАРР : m esh fixation (tacking)
  31. 32. М. Кучер ТАРР : peritoneum closure
  32. 33. Prognosis : hernia recurrence <ul><li>hernia recurrence rates after primary groin hernia repair : from < 1% to almost 15% </li></ul><ul><li>after repair of recurrent groin hernia: < 3% of second recurrence </li></ul><ul><li>after incisional hernia repair may exceed 30% </li></ul><ul><li>closure under excessive tension </li></ul><ul><li>failure to exclude adjacent musculoaponeurotic defects </li></ul><ul><li>failure to identify and use an adequately strong musculoaponeurotic margin </li></ul><ul><li>wound infection </li></ul><ul><li>inadequate collagen formation in the wound (malnutrition, concomitant therapeutic administration of corticosteroids or antimetabolites) </li></ul><ul><li>chronically high intraabdominal pressure </li></ul>
  33. 34. Long term randomized clinical trial of non mesh versus mesh repair of primary inguinal hernia <ul><li>Prospective studies and meta-analysis have demonstrated the increased recurrence rate with no mesh technique </li></ul><ul><li>The 10 year cumulative hernia recurrence rate of 17% for non mesh and 1% for mesh repair </li></ul><ul><li>Half of the recurrences after 3 years follow up </li></ul><ul><li>Van Veen Rat et al Br. J. Surg 2007; 94;505-10 </li></ul>
  34. 35. Two meta-analyses (Memon 2003 & McCormack 2003) Laparoscopic vs Open hernia repair <ul><li>Both conclude that: </li></ul><ul><li>- lap hernia takes longer to perform </li></ul><ul><li>- lap hernia associated with less pain </li></ul><ul><li>- lap hernia ---- faster to return to normal activity </li></ul><ul><li>- lap hernia recurrence rates similar or lower </li></ul><ul><li>- lap hernia complication rare similar or lower </li></ul><ul><li>BUT SOME RARE SEVERE UNIQUE COMPLICATIONS in lap hernia </li></ul>
  35. 36. М. Кучер Hernia complications <ul><li>Inflammation </li></ul><ul><li>Incarceration </li></ul><ul><li>Obstruction </li></ul><ul><li>Strangulation </li></ul><ul><li>Trauma </li></ul><ul><li>Malignancy </li></ul>
  36. 37. М. Кучер if those organs cannot slide easily back into the abdomen,the hernia is said to be irreducible. Irreducible hernias are often painful and can lead to complications Hernia complications
  37. 38. М. Кучер if the intestine becomes trapped in the hernia sack it is said to be incarcerated
  38. 39. М. Кучер if the neck of the hernia sack actually pinches off the supply of blood to those organs which have become trapped inside, the hernia is said to be strangulated Severe pain Fever Vomiting Gangrene
  39. 40. М. Кучер strangulation of antimesenteric portion of the bowel (Richter’s hernia) No signs of obstruction!!! Stragulated hernia Maydl’s hernia
  40. 41. М. Кучер strangulated hernia is a medical emergency that requires immediate surgery
  41. 42. Intraoperative options <ul><li>Intestine viability </li></ul><ul><li>Kocher’s rule </li></ul>
  42. 43. Mayo umbilical hernia repair
  43. 44. Incision hernia
  44. 45. Incision hernia repair <ul><li>Recurrence rates: </li></ul><ul><li>34-54% Non Mesh (Anthony,2000) </li></ul><ul><li>24 % Mesh (Luijendijk,2000) </li></ul>
  45. 46. Onlay placement <ul><li>GORE-TEX DUALMESH </li></ul><ul><li>The biomaterial features two functionally distinct surfaces: a closed structure surface for reduced tissue attachment and a macroporous structure surface for faster tissue attachment. </li></ul>
  46. 47. sublay/inlay placement <ul><li>VYPRO mesh is placed preperitoneally as a sublay </li></ul><ul><li>Direct contact between the mesh and intraperitoneal structures must be avoided by using intact peritoneum </li></ul>
  47. 48. PROLENE MESH: major comlication <ul><li>The placement of the mesh in the preperitoneal, retromuscular position with a wide overlap of at least 5 cm over the hernia defect in all directions was introduced in the late 1980’s. The refinement of this method decreased the recurrence rates to as low as 3.5% making it to be declared the standard of care of ventral hernias. However implantation of the mesh by open techniques requires wide dissection of soft tissue contributing to an increase in wound infection and wound- related complications </li></ul>
  48. 49. Ideal hernia mesh <ul><li>Remains strong and supple </li></ul><ul><li>Does not shrink </li></ul><ul><li>Incorporates rapidly to the abdominal wall </li></ul><ul><li>Provides for permanent repair </li></ul><ul><li>Does nor adhere to viscera </li></ul><ul><li>Does nit become infected </li></ul><ul><li>Not carcinogenic or allergenic </li></ul><ul><li>Causes no pain or discomfort </li></ul><ul><li>Easy to handle </li></ul><ul><li>inexpensive </li></ul>
  49. 50. Incision hernia repair <ul><li>PROCEED* Surgical Mesh can be used inside the abdomen for incisional/ventral hernias. It is a multi-layered product with a newer lightweight construction that allows a more flexible scar tissue to develop. PROCEED also has a layer of fabric that is biodegradable and separates the supportive mesh from the surrounding organs. As healing progresses, the material dissolves away. </li></ul>
  50. 51. <ul><li>ULTRAPRO* Partially Absorbable Mesh. It is the only mesh in the United States that is partially biodegradable, and is the only mesh with all the features of lightweight design -- thin filament size, large pore construction, and absorbable materials. ULTRAPRO mesh creates a strong yet flexible scar tissue that mimics the natural abdominal wall, unlike the rigid, thick scar tissue that can form with heavyweight, small pore meshes. </li></ul>
  51. 52. New biological mesh <ul><li>Allogenic (cadaveric) </li></ul><ul><li>Xenogenic (bovine or porcine) </li></ul><ul><ul><li>Surgisis – laminates of porcine collagen from small intestine submucosa </li></ul></ul>