Repair of incisional hernia continues to pose a challenge to the general surgeon. A combination technique best suited for mid line incisional hernias with loss of domain is presented.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.There are different kinds of hernia, each requiring a specific management or treatment.
SIGNS AND SYMPTOMS
By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.
Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ.
Hernias are not tears in the tissue but are openings in the adipose tissue. It is possible for a hernia to come and go, but in most cases a pain will persist.
Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.
Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Strangulated hernias are always painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.
In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.
CAUSES OF HERNIA
Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, and incorrect posture.
Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate).
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.There are different kinds of hernia, each requiring a specific management or treatment.
SIGNS AND SYMPTOMS
By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.
Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ.
Hernias are not tears in the tissue but are openings in the adipose tissue. It is possible for a hernia to come and go, but in most cases a pain will persist.
Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.
Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Strangulated hernias are always painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.
In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.
CAUSES OF HERNIA
Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, and incorrect posture.
Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate).
Incisional Hernia, risk factors, management and relation to Surgical Abdomina...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
Repair of incisional hernia! A anatomical and technical challenge.KETAN VAGHOLKAR
Incisional hernia is the most challenging problem in abdominal surgery. Open method provides the most sound and longlasting cure to the problem. The recurrence rate with a well done open technique is very low.
Results of incisional hernia repair are poor. Centralized hernia surgery is a prerequisite for improvement of clinical outcomes. Center for a hernia and abdominal wall reconstruction should be an essential component of a university hospital. A hernia and abdominal wall reconstructive surgery is a practical and academic sub-specialization.
European Hernia Society (EHS) 2014 guidelines : Closure of abdominal wall inc...Jibran Mohsin
This presentation includes the latest(2014) European Hernia Society (EHS) guidelines regarding the optimal technique and suture material for the closure of elective mid-line abdominal incisions in order to decrease the frequencies of complications especially incisional hernia, wound dehiscence and burst abdomen.
Surgical management of giant inguinoscrotal herniasKETAN VAGHOLKAR
Giant Inguinoscrotal Hernias continue to pose a technical challenge to the general surgeon. Awareness of all the possible contents prior to surgery is pivotal in avoiding disastrous complications. A case of a giant inguinal hernia with transverse colon as its content is presented to highlight the diversity of contents. The natural history and surgical options for treating giant inguinoscrotal hernias is discussed. Giant inguinoscrotal hernias should be operated upon at the earliest after contrast enhanced CT evaluation for ascertaining the contents. Open surgical approach to such cases is the safest.
Incisional Hernia, risk factors, management and relation to Surgical Abdomina...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
Repair of incisional hernia! A anatomical and technical challenge.KETAN VAGHOLKAR
Incisional hernia is the most challenging problem in abdominal surgery. Open method provides the most sound and longlasting cure to the problem. The recurrence rate with a well done open technique is very low.
Results of incisional hernia repair are poor. Centralized hernia surgery is a prerequisite for improvement of clinical outcomes. Center for a hernia and abdominal wall reconstruction should be an essential component of a university hospital. A hernia and abdominal wall reconstructive surgery is a practical and academic sub-specialization.
European Hernia Society (EHS) 2014 guidelines : Closure of abdominal wall inc...Jibran Mohsin
This presentation includes the latest(2014) European Hernia Society (EHS) guidelines regarding the optimal technique and suture material for the closure of elective mid-line abdominal incisions in order to decrease the frequencies of complications especially incisional hernia, wound dehiscence and burst abdomen.
Surgical management of giant inguinoscrotal herniasKETAN VAGHOLKAR
Giant Inguinoscrotal Hernias continue to pose a technical challenge to the general surgeon. Awareness of all the possible contents prior to surgery is pivotal in avoiding disastrous complications. A case of a giant inguinal hernia with transverse colon as its content is presented to highlight the diversity of contents. The natural history and surgical options for treating giant inguinoscrotal hernias is discussed. Giant inguinoscrotal hernias should be operated upon at the earliest after contrast enhanced CT evaluation for ascertaining the contents. Open surgical approach to such cases is the safest.
Slings versus POP meshes ICS Educational Course - S Paulo BrazilCassio Riccetto
This presentation is focused on the differences and similarities between mid-urethral slings and POP meshes. Issues regarding FDA warnings are also addressed.
Single staged surgical procedure for recurrent incisional hernia with trophic...KETAN VAGHOLKAR
Incisional hernia by itself is a very challenging surgical disease to treat. Recurrent incisional hernia with trophic ulceration adds to the complexity of the problem making surgical treatment more difficult. A case of a recurrent incisional hernia with trophic ulceration treated by a single staged procedure comprising of wide excision of the trophic ulcer with repair of the incisional hernia is presented to highlight the applicability of a single staged procedure as a viable option for managing such complex hernias.
Background: The development of a pseudocyst after mesh repair of an incisional hernia is a rare complication. Both diagnosis and management pose a great challenge to the attending surgeon. Therefore, the need to report such
an uncommon complication and its management in order to create awareness of this distinct though rare entity. Case
report: A pseudocyst formation following an onlay mesh repair of an incisional hernia is reported. Contrast-enhanced
CT scan was diagnostic. It revealed a well-formed cyst with no communication with the peritoneal cavity. Complete
excision of the cyst was curative. Conclusion: Pseudocyst formation is a rare complication following mesh repair.
Contrast-enhanced CT scan is essential for confirming the diagnosis. Complete surgical resection of the cyst is the
mainstay of surgical treatment.
Mahendra Azad et al. GAINT ODONTOGENIC KERATOCYST OF MANDIBLE OPERATED UNDER LOCAL ANESTHESIA- A CASE REPORT. JOURNAL OF DENTAL HEALTH & RESEARCH (VOL. 1, ISSUE 2, JUL - DEC 2020): 24-2
Retro rectus mesh repair for umbilical hernia in adults: a study of 50 cases.KETAN VAGHOLKAR
ABSTRACT
Background: Umbilical hernia is one of the most commonly encountered hernia in surgical practice. A variety of repairs have been tried our ranging from open to laparoscopic. However controversy still persists as to which type of repair is the gold standard for umbilical hernia. Open technique comprises of the onlay mesh repair which is known to develop a variety of complications. Even laparoscopic approach also has failure rates as well as local complications. The aim of the study was to evaluate the surgical outcome of open retro rectus mesh repair for adult umbilical hernias.
Methods: 50 consecutive cases of umbilical hernia were repaired by open technique with retro rectus placement of mesh.
Results: There were no local complications or any recurrence in any of the fifty patients.
Conclusions: Retro rectus placement of mesh in open repair of umbilical hernia in adults is a safe and effective modality of treatment.
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...Dr./ Ihab Samy
Hany F. Habashy MD.a , Ihab S. Fayek MD b , Mohamed I.Abd el aziz MD a
a:Department of Surgery-Fayoum University Hospital-El Fayoum , Egypt.
b:Department of Surgical Oncology –National Cancer Institute – Cairo University ,Egypt.
Kasr el-aini journal of surgery Volume 14, No.2, May 2013
Fournier’s gangrene of the scrotum after inguinal hernia repair: case reportDrKetanVagholkar
Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.
Fournier’s gangrene of the scrotum after inguinal hernia repair: case reportKETAN VAGHOLKAR
Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay
Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis
is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is
a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a 17-year-old boy is reported to highlight the
diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along
with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges, the dilemma
of selecting the best option for removing Meckel’s diverticulum, and the choice of hernia repair are discussed. Littre’s hernia is
invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel and Meckel’s diverticulum
prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for
other age groups is advisable.
Hyperbaric oxygen therapy a boon for complex post traumatic woundsKETAN VAGHOLKAR
Post-traumatic wounds especially after run over accidents are difficult to manage. The vascularity and regenerative potential of the tissues is severely compromised. Surgical intervention is of limited value. A conservative approach with concomitant hyperbaric oxygen therapy (HBOT) serves as a great salvage in such cases. A case of post-traumatic forefoot gangrene in a 27-year-old laborer is presented to highlight and create an awareness of the potential benefit of HBOT in salvage of distal parts of the lower extremity where the blood supply is severely compromised.
Deep vein thrombosis (DVT) usually affects the deep vein of the legs, though it may also occur in the veins of the arms, mesenteric and cerebral
veins. Venous thromboembolism can cause sudden pulmonary embolism with instantaneous death. In patients who have developed deep vein
thrombosis there is likelihood of recurrent thrombosis and post thrombotic syndrome. Deep venous thrombosis is preventable in majority of the
cases. Understanding the etiopathogenesis, clinical presentation, evaluation and management is essential for both prevention and management
thereby reducing the morbidity and mortality associated with the disease.
Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...KETAN VAGHOLKAR
Background: Fluid collection in a femoral hernia sac designated as a femorocele is an
extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and
one case of bilateral femorocele have been reported in English literature. Objective: Thus
making the case presented the second case of bilateral femorocele in English literature.
Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease
who had undergone dual valvular replacement with ascites due to cardiac cirrhosis
is presented to highlight the surgical challenges in management of such a rare case. Discussion:
Pathophysiology, clinical features, investigations and managemeny of femorocele
are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is
diagnostic. Open surgery in the form of dissection of sac with high ligation followed by
obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.
Sliding inguinal hernia continues to be the most challenging hernia to treat. Both diagnosis and treatment pose a
dilemma to the attending surgeon. Understanding the pathological anatomy of the sliding inguinal hernia is essential
for optimal choice of surgical procedure without causing damage to the involved viscera. A case of sliding inguinal
hernia is presented to highlight the diagnostic and technical challenges for repair of sliding hernia. Majority of sliding
hernias are diagnosed at the time of surgery. Sigmoid colon is a commonest content in a left sided sliding hernia.
Bevan’s technique is best suited to deal with the sac followed by Lichtenstein tension-free mesh repair.
Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.
Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a
great challenge to the attending surgeon. There are various variants of embryological abnormality of the
processes vaginalis manifesting in different forms. Understanding the embryological development of the
processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical
option for treating these rare cases.
Carbuncle is a confluent folliculitis that is infection affecting multiple hair follicles leading to multiple
sinuses discharging pus. It is commonly seen on the back of immuno-compromised patients. Admission to
hospital with aggressive treatment, both systemic and locally is necessary. Optimisation of co-morbidities
such as diabetes, adequate hydration, and antibiotics and are mainstay of initial treatment. Surgical
intervention in the form of debridement and desloughing followed by wound care is the next line of
management. Patient education at the time of discharge is necessary for prevention of recurrence.
Foreign body in the male urethra: case reportKETAN VAGHOLKAR
Cases of self-inserted foreign bodies into the lower urinary tract are uncommon. They are associated with a mental illness called polyembolokoilomania. The site, size and nature of the foreign body determines both the symptomatology and complications. A case of self-inserted needle into the penile urethra by a 15-year-old boy is presented. A plain X-ray of the pelvis revealed the needle. The needle was successfully removed by cystoscopy. Plane X-ray imaging and CT scan are essential to locate the site, size, and nature of the foreign body. Endoscopic approach is preferred in majority cases. Psychiatric counselling in the post-operative period is required to prevent further episodes of reinsertion of such foreign bodies.
Morel-Lavallée Lesion: Uncommon Injury often MissedKETAN VAGHOLKAR
Introduction: Morel-Lavalleé lesion is an uncommon closed degloving injury usually affecting the lower extremity. Although these lesions have
been documented in literature, yet there is no standard treatment algorithm for the same. A case of Morel-Lavallée lesion following blunt injury to
the thigh is therefore presented to highlight the diagnostic and therapeutic challenges in managing such lesions. The aim of presenting the case is
to create awareness of clinical presentation, diagnosis, and management of Morel-Lavallée lesions, especially in the setting of polytrauma
patients.
Case Report: A case of Morel-Lavallée lesion in a 32-year-old male with history of a blunt injury to the right thigh caused by a partial run over
accident is presented. A magnetic resonance imaging (MRI) was done to confirm the diagnosis. A limited open approach for evacuating the fluid
in the lesion was performed followed by irrigation of the cavity with a combination of 3% hypertonic saline and hydrogen peroxide in order to
induce fibrosis to obliterate the dead space. This was followed by continuous negative suction accompanied with a pressure bandage.
Conclusion: A high index of suspicion is necessary especially in cases of severe blunt injuries to the extremities. MRI is essential for early
diagnosis of Morel-Lavallée lesions. A limited open approach is a safe and effective option for treatment. The use of 3% hypertonic saline along
with hydrogen peroxide irrigation of the cavity to induce sclerosis is a novel method for treating the condition.
Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...KETAN VAGHOLKAR
Background: Traumatic lumbar hernia is due to shearing of bony insertions of the muscle
in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes
fixation of the mesh extremely difficult. Hence, the need to develop a new technique. Case
report: A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar
hernia. He had a severe two wheeler accident. Following the accident he had undergone
various surgical interventions for a fractured pelvis with a deglowing injury involving the
right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia
for which he had undergone open mesh repair. Subsequently he developed recurrence of
the post traumatic right-sided lumbar hernia. After complete investigation he underwent
open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and
was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with
bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes
drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles.
They were double-breasted to cover the mesh. Postoperative outcome was excellent
with no recurrence for the last six months. Discussion: The various anatomical and technical
considerations of bone fixation of the mesh for hernia repair are discussed. Conclusion:
Bone fixation of the mesh with bone anchors is a viable option especially in cases where
there is severe attenuation of adjacent muscles for mesh fixation.
LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...KETAN VAGHOLKAR
Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of
laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention.
As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to
evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and
safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients
who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied
prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right
hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes.
In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure.
10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic
cholecystectomy is a safe and viable option for treating acute calculous cholecystitis
Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)KETAN VAGHOLKAR
Background: Appendicectomy is one of the common procedures performed by a general surgeon. However,
the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore
there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The
study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and
postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised
into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised
25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative
findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced
need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed
in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure
for appendicectomy.
Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to
be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation
and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ
involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal
tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various
surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was
commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia
were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early
histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant
adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis
Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or
contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly
suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical
intervention for complications is the mainstay of treatment.
PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...KETAN VAGHOLKAR
Background: Perforative peritonitis poses a significant diagnostic and therapeutic challenge to the attending
surgeon. Delay in diagnosis followed by sub-optimal treatment may lead to many complications, thereby increasing both
morbidity and mortality. This is by virtue of various factors which affect the prognosis. Hence the need arises to identify
these prognostic factors. Aims and Objectives: To study the various etiological factors of perforative peritonitis and to
identify prognostic factors and comorbid conditions which influence the outcome in perforative peritonitis. Materials
and Methods: 50 patients with an established diagnosis of perforative peritonitis due to various aetiologies confirmed
by clinical and radiological investigations were included in the study and studied prospectively. On admission to the
hospital, various haematological and radiological investigations were conducted to confirm the diagnosis. Patients
subsequently underwent surgical intervention. Postoperative recovery and outcomes assessed. Results were tabulated
and statistically analysed. Results: The mean age of patients in the study was 36.5 ±5 years. Patients who presented
in an advanced stage developed complications. The majority of patients were males. The interval between the onset
of symptoms and operative intervention was directly related to postoperative complications. Pneumoperitoneum was
the most common x-ray finding, followed by dilated bowel loops with free fluid in the peritoneal cavity as the most
common ultrasonography finding. Tachycardia and oliguria, which were markers of the severity of the disease process,
were associated with an increased rate of complications. Peptic ulcer perforation was the most common, followed by
perforations caused by infective aetiology. Perforations caused by infective aetiology had a higher rate of complication.
Primary closure of the perforation was the most commonly performed procedure. Significant abdominal contamination
found intraoperatively contributed to a negative outcome, as were comorbid conditions, which also increased the
complication rate significantly. Conclusion: Delayed intervention after the onset of symptoms, tachycardia, oliguria
and comorbidities are associated with a higher complication rate. Radiological investigations help in confirming the
diagnosis. Infective aetiology of the perforation and extensive peritoneal contamination was associated with higher
complication rates. Prompt and aggressive resuscitation on admission, optimum antibiotic administration, and early
meticulous surgical intervention can reduce morbidity and mortality to a bare minimum.
COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...KETAN VAGHOLKAR
Background: Skin approximation is a very important step in a surgical operation. The quality of skin
approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications.
Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare
traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound
complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients
are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation).
The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation)
had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction.
Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
Background: Sigmoid Volvulus is the third most common cause of colonic obstruction and accounts for
2-4% of intestinal obstructions. A variety of abdominal and functional factors contribute to the development of sigmoid
volvulus. The progression of pathology is extremely rapid. Hence, understanding these factors enables early diagnosis
and prompt surgical intervention. Aims: 20 cases of surgically treated sigmoid volvulus were studied retrospectively
to identify and evaluate various factors causing morbidity and mortality in these patients. Results: The condition was
commonly seen in males, especially those who were institutionalized and were using laxatives for over 5 years. The
mean age was 65.2 years. Co-morbidities were a common accompaniment. 13 patients had diabetes, 12 patients had
hypertension, 2 patients had ischemic heart disease and 9 patients had the neurological disease (Parkinson’s disease).
6 patients had single co-morbidity, 13 patients had 2 co-morbidities and 1 patient had 3 co-morbidities. A plain X-ray
of the abdomen was diagnostic in all cases. The mean time interval from the onset of symptoms to hospital admission
was 8.1 hours, the time interval from hospital admission to confirmation of diagnosis was 2.1 hours. The mean time
interval from diagnosis to surgical intervention was 3.2 hours. The surgical options exercised were resection anastomosis
with a proximal diversion in 13 patients, Hartmann’s procedure in 6 patients, and primary resection anastomosis in
1 patient. Post-operative complications included ileus in 16 patients, stomal dysfunction in 4 patients, and surgical
infections in 10 patients. The mean duration of stay in hospital ranged from 7-13 days. Only 1 patient who had 2
co-morbidities developed complications and succumbed. Conclusion: Prompt diagnosis, optimization of haemodynamic
status including co-morbidities is essential before contemplating surgical intervention. Resection anastomosis with a
proximal diverting stoma is best suited for patients who have not developed a colonic perforation whereas Hartmann’s
procedure is indicated in patients presented with perforative peritonitis.
Factors affecting mortality in burns: a single center studyKETAN VAGHOLKAR
Background: Burns injury continues to be the greatest challenge to the trauma surgeon. A multitude of factors determine the mortality in burns patients. The present study aims at identifying those factors which have a significant impact on mortality in burns patients.
Methods: A total 80 patients presenting with burns injury were studied prospectively. Various factors which included age, sex, aetiology, mode of injury, total body surface area which is burnt (BSA), duration of stay, time interval up to admission, pregnant state, inhalation injury, systemic complications, wound complications, and psychological impact were studied.
Results: The mean age was 24.07 years. 59 were females, 21 were males. 19 (23.75%) cases were suicidal in aetiology whereas the remaining 61(76.25%) were accidental. Flame injury was the most common mode of injury in 65 patients (81.25%). The mean BSA in the study was 53.5% whereas the mean BSA in those patients who expired was 71.4%. Mean duration of stay in hospital was 6.55 days whereas mean time interval between burns injury and admission to hospital was 101.33 minutes. All 12 pregnant women had spontaneous miscarriages with a mortality in 11 patients. Inhalation injury was seen in 49 patients (61%) with mortality of 42 (83.7%) patients. Systemic complications seen in 60 patients mortality and BSA was high in patients who had infection. 31 patients in the study had severe depression with a mortality of 91.32%. 50 out of the 80 patients studied expired.
Conclusions: Increased age, BSA, mode of injury, presence of inhalation injury, systemic complication, pregnant state, wound infection and depression had a significant impact on the mortality of burns patients.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Combined Tissue and Mesh repair for Midline Incisional Hernia
1. COMBINED TISSUE AND
MESH REPAIR FOR MIDLINE
INCISIONAL HERNIA
Dr. Ketan Vagholkar
MS, DNB, MRCS(Eng), MRCS(Glasgow), FACS
Consultant General Surgeon
2. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1890
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Combined Tissue and Mesh Repair for Midline Incisional Hernia
(A Study of 15 Cases)
Authors
Dr. Ketan Vagholkar1
, Dr. Abhijit Budhkar2
1
Professor of Surgery,MS, DNB, MRCS (Eng), MRCS (Glasg), FACS, Dr. D. Y. Patil Medical College,
Navi Mumbai 400706. MS. India.
2
Senior Surgery Resident, MBBS, Dr. D. Y.Patil Medical College,Navi Mumbai 400706.MS. India
Correspondence Authors
Dr. Ketan Vagholkar
Annapurna Niwas, 229 Ghantali Road. Thane 400602, MS. India
Email: kvagholkar@yahoo.com
ABSTRACT
Background: Midline incisional hernia is one of the most complex hernia to treat. A variety of repairs have
been advocated. However no single repair can be called the best. A combination of repair methodologies is
therefore the only hope for developing a repair which will have least recurrence rate.
Objectives: The present study aimed at evaluating a combined tissue and mesh repair for midline incisional
hernias.
Materials and Methods: Fifteen patients undergoing a combined tissue and mesh repair were evaluated. The
tissue repair comprised of creating flaps from the rectus sheath to create a new midline. This was followed by
mesh reinforcement of the newly created midline.
Results: There were no recurrences in any of the patients at a mean follow up of 16.7 months.
Discussion: The pathophysiology and technical details are evaluated and discussed.
Conclusion: A combined tissue and mesh repair is an excellent and economical option for midline incisional
hernias
Key Words: Incisional, Hernia, Open, Tissue, Mesh, Repair.
www.jmscr.igmpublication.org Impact Factor 3.79
ISSN (e)-2347-176x
3. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1891
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INTRODUCTION
Incisional hernia is one of the most morbid
complications after abdominal surgery. [1] The
etiology of incisional hernia may be variable. It
depends upon variety of factors ranging from age
to wound infection.Majority of these hernias
develop within 3yrs of primary surgery. [1] Gross
distortion of tissues accompanied with poor
wound healing poses a challenge to successful
repair. A wide variety of repairs ranging from
open to laparoscopic have been proposed by
surgeons from every continent of the world.[2]
The choice of repair is a matter of individual
experience and surgical outcome.
Objective
Developing a new method combining anatomical
repair by creating flaps from local tissues with
reinforcement by a mesh for midline incisional
hernias.
Inclusion Criteria
All patients with midline incisional hernias with
defect size of any length were included in the
study. A period of 6 months was ensured to have
elapsed after the primary surgery for every patient
before contemplating repair of the hernia.
Exclusion Criteria
Hernias complicated by signs of obstruction and
strangulation Patients with intra-abdominal
pathology diagnosed by CT scan
Materials and Methods
On admission to hospital a detailed proforma was
completed which included demographic details,
details of primary surgery,post-operative
complications, presence of comorbidities and
treatment for the same. Control of comorbidities
like diabetes mellitus, hypertension and COPD
were achieved prior to hernia repair.A contrast
enhanced CT of the abdomen was performed in all
patients in order to rule out any intra-abdominal
pathology. The size of defect was assessed in
order to determine the presence of loss of domain.
All patients were admitted one day prior to
surgery and operated by the primary author (K
V)in order to maintain uniformity of surgical
technique.
Technical Details
An elliptical incision was made encompassing the
scar of previous surgery. Incision was deepened
and extended laterally all around in order to avoid
perforation of the sac and damage to underlying
structures. The overlying scarred skin was
excised. (Figure I)Dissection was carried laterally
till neck of sac was reached.Same procedure was
carried out superiorly and inferiorly. The entire
circumference of fibrous ring was delineated.
(Figure II)The sac was not opened in cases where
there were no adherent loops,loculations or
preoperative complications pertaining to hernia.
The fat overlying the surrounding aponeurosis
was cleared. Two vertical incisions were made
approximately 1 inch lateral and parallel to fibrous
defect. (Figure III)The flaps were created from
the anterior rectus sheath and reflected medially
on either side. These flaps were approximated in
the midline in a tension-free manner by two rows
of 1-0 ethilon sutures (figures IV, V & VI)Rectus
abdominis muscle on either side was dissected
free at the site of tendinous insertions thus
creating a retro-rectus space on either side.A
Polypropylene mesh was then laid extending from
4. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1892
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the superior point to inferior point of newly
created midline. This mesh was fixed in the
midline with non-absorbable sutures. It was
stretched uniformly on either side, passed under
the rectus muscle on either side and fixed to the
lateral cut edge of the anterior rectus sheath.
(Figure VII)Utmost care was taken to ensure a
well spread out tension-free mesh placement.Two
negative suction drains were kept over the mesh
and brought out through two separate stab
incisions.Approximation of subcutaneous tissue
was done by 2-0 Vicryl.Skin was approximated
with staples.Precautions were taken to prevent
wound infection.Aperioperative course of
antibiotics comprising of 1 gm Ceftriaxone and
500mg Amikacin were administered.Irrigation of
subcutaneous tissue was done after its
approximation, prior to skin closure.Skin
approximated with staples. Topical
Chloramphenicol powder was sprinkled over
stapled suture line before applying a sterile
dressing.The post-operative course of each patient
was monitored. Ryle’s tube which was introduced
for all patients intraoperatively was removed after
24 hours. The per urethral catheter wasalso
removed after 24 hrs. Drains were however left in
situ. The criteria for removal of drains was drain
volume output of less than or equal to 20 cc per
day for two consecutive days.Post-operative
complications in the form of development of
seroma, hematoma,wound infection, other
complications related to comorbidities were
observed and notedWound infection was defined
as any redness of surrounding skin with or without
discharge.Staples were removed on 12th
post-
operative day and the use of an abdominal corset
was advised for aperiod of 3 months after hernia
repair.
RESULTS
15 consecutive patients who underwent combine
repair for incisional hernia were studied
prospectively. (Table 1) The mean age was 47 yrs.
+/- S.D of 8.3. There were 13 female and 2 male
patients in the study.Nine patients had
predominantly upper midline defects. Five had
predominantly lower midline defects and one had
a combination of both. The mean duration for
removal of drains was 3.7 days. None of patients
developed seromas. Three patients developed
superficial hematomas which did not necessitate
any further intervention. One patient developed
superficial infection in the form of redness and
was administered a short course of antibiotics.
Four patients developed ileus in post-operative
period and one developed exacerbation of COPD
which was controlled by medications. None of
patients required ICUsupport. The mean hospital
stay of patients was 6.2 days. The median follow
up of patients was 12 months with a range of 6 to
15 months. There were no recurrences.
5. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1893
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Table 1 Results of the Case Study.
Sr
No
Age
(yrs.)
Sex Type of
incision
Drain
removal
(Days)
Seroma Hematoma Infection Other
complications
Duration
of stay
(Days)
Follow
up
(months)
1 45 F LM 4 - - - - 5 6
2 52 M UM 5 - - - ILEUS 7 12
3 39 F UM+LM 3 - - - ILEUS 5 11
4 43 F UM 3 - - - - 5 14
5 56 F UM 4 - - - - 5 12
6 40 F UM 3 - - - - 5 8
7 35 F LM 3 - - - - 5 14
8 59 F LM 5 - - - ILEUS 8 9
9 62 F LM 3 - - - COPD 7 6
10 36 F LM 3 - + - ILEUS 7 9
11 45 F LM 4 - + + - 9 15
12 44 M UM 5 - - - - 7 12
13 56 F LM 4 - - - - 7 13
14 45 F LM 3 - - - - 6 7
15 49 F LM 4 - + - - 6 13
(LM is lower midline, UM is upper midline)
DISCUSSION
Incisional hernia repair is the biggest surgical
challenge to the general surgeon. The entire
science of surgery is based on the assumption that
the patient has good healing powers. However in
the context of incisional hernia, extensive damage
to the regenerative elements of the affected tissues
leading to excessive formation of scar tissue has
already occurred. [1] These hernias usually arise
from wounds which developed partial dehiscence.
A hernia sac is formed and grows rapidly due to
continuous exposure to high pressure. The defect
also widens rapidly with time giving rise to
herniation of a large volume of abdominal
contents into the hernia sac. Neglect of the lesion
and haphazard use of irregularly fitted abdominal
corset leads to more complications developing in
the hernia. Development of loculations with
superimposed adhesions within the sac
predisposes to obstruction and strangulation. [3]
Strangulation by virtue of a narrow neck is
uncommon in incisional hernias as the defect is
quiet large in majority of cases. However
strangulation of contents may be a common
occurrence in longstanding hernias with internal
loculations and adhesions. Loss of domain is
another issue which needs to be recognized.Loss
of continuity of the musculo-aponeurotic
structures leads to shortening of contractile
elements of the structures thereby increasing the
size of the defect. [3] This poses a great
anatomical challenge for repair.Having
understood the natural history of incisional hernia
thesurgeon needs to take into consideration
anatomical, physiological,and pathological factors
individually in every patient before deciding the
technique for the repair. [4]
Increasing age is associated with weakening of
tissues thereby predisposing to weakening of
wound healing process, inadequate scar tissue
formation and poor tensile strength of the head
6. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1894
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tissues. [1] All these factors predispose to
development of incisional hernias.In the present
case series the mean age of patients was 47 +/- SD
of8.3 suggesting that the incidence increases with
advancing age.
In the present study 13 were females and 2 were
male patients. Women who have had previous
pregnancies usually have a weakened abdominal
wall. Any of the common operative procedures
ranging from a laparoscopic tubal ligation to
hysterectomy in the female population have a high
predilection to develop incisional hernias.
Excessive stretching of the tissues especially the
musculo-aponeurotic component predisposes to
herniation. In the series presented all the
thirteenfemale patients had previous pregnancies
and all these patients had hernias developing
following gynecological procedures which
included tubal ligation,caesarean section and
hysterectomy. Whereas a previous laparotomy for
a septic lesionwas seen in the two males who had
undergone surgery for perforation peritonitis.
Type of incision has a great impact on
development of incisional hernias. Upper midline
incisions (UM) are usually made for septic
conditions whereas lower midline (LM) incisions
are made for pelvic surgeries. There is no specific
predilection for herniation with respect to the
upper midline or lower midline.Midline incisions
are more predisposed to development of hernias as
compare to a paramedian or a transverse incision.
The midline of the abdomen comprisesthe
lineaalba which is aaponeurotic intersection of
fibers of the rectus sheathfrom either side. It is a
relatively avascular line as compared to the
surrounding tissues. Thedecussation of
aponeuroticfibres by itself is an anatomically
weak area and is always a potential site for
herniation when exposed to transient rise in intra-
abdominal pressure as compared to other
structures. Suturing of the lineaalba therefore has
to be done meticulously with astrong
nonabsorbable suture material with bites to be
taken atleast 1cm from the edge on eitherside in
order to prevent cut through and ensure firm
approximation of the cut edges. Sparse blood
supply of the lineaalba limits strong healing and
scar tissue formation as compared to other areas
of the body. Lower abdomen has a precarious
anatomical configuration wherein the lineaalba
continues to remain same but posterior rectus
sheath ceases to exist midway between the
umbilicus and the pubic symphysis. Even the
lineaalba is weaker infraumbilically as compared
to supraumbilical portion. Maximum point of
weakness in the lineaalba is usually in the
periumbilical region. It is this area where
herniation takes place. Subsequently the defect
enlarges in the direction of the line of least
resistance. Therefore it is of utmost importance
during the course of repair of midline incisional
hernias to reconstitute a strong midline which is
pivotal for a successful long lasting outcome.
In the technique presented as there was a
deficiency in the midline, approximation of the
edges would be futile as it would put a lot of
tension on the suture line thus violating the basic
doctrine of tension free repair.
7. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1895
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Figure I:(RL is the border of the rectus muscle in
resting state of the abdomen while CR is medial
border of the rectus muscle on contracting the
anterior abdominal wall. PD is the defect which
exhibits loss of domain)
(Figure I) It is very important therefore to create
an aponeurotic tissue cover. Advantage is taken of
the anterior rectus sheath.
Figure II (The black arrows point towards the
edge of the defect after completion of herniotomy)
[5] A vertical incision made 1 to 1.5 inch lateral
and parallelto the edge of the defect on either side
provides aponeurotic flaps. Approximation of the
medial cut edge of these flaps of the anterior
rectus sheath yields a tissue gain of approximately
3inches in the central deficient portion of
abdomen.
Figure III: (The black arrows indicate the site of
longitudinal incisions made on the anterior rectus
sheath on either side. The purple arrows point
towards the medical cut edges of the anterior
rectus sheath flaps. The blue arrows point towards
the lateral cut edge of the anterior rectus sheath)
(Figure III) Since adequate tissue is now available
by virtue of creating flaps from the anterior rectus
sheath, the approximation of these flaps in the
midline is tension free with very low chances of
cut through or give way. In the technique
presented a double suture line in the midline was
achieved by two different types of
approximations. The inner suture line was taken
with horizontal mattress suture using
nonabsorbable suture material. This was
approximately taken 1cm from the cut edge.
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Figure IV:(The medial edges of the anterior
rectus flaps reflected medially marked by purple
arrows are approximated with horizontal mattress
sutures taken approximately 1 cms from the edge
marked by the faint black line)
(Figure IV). Finally the free cut edge was
approximated with continuous running suture of
non-absorbable material.
Figure V: The free medial edges of the flaps
marked by purple arrows are approximated with a
running suture after tightening the horizontal
mattress sutures held by artery forceps.)
(Figure V) The end result of this surgical exercise
was a strongly reconstituted midline.
Figure VI : (The newly created midline marked
by purple arrows)
(Figure VI) In cases where one anticipates undue
tension on suture line a single suture line
approximating the cut edges of the anterior rectus
sheath flaps will suffice. The rectus muscle on
either side is freed of the tendinous intersections
posteriorly as well thereby creating a space behind
it.
As discussed previously the repair ofincisional
hernia is based on assumption of weakened tissue
with presumably poor healing properties therefore
as a safeguard it is prudent on the part of surgeon
to reinforce anatomically repaired defects.[6,7,8]
This is based done by use of polypropylene mesh
which can safely be placed on the repaired
rectussheath. Placing the mesh as an inlay over the
peritoneum can prove to be dangerous as it has
propensity to cut through the peritoneum and
project into the peritoneal cavity. This can led to
extensive adhesions predisposing to obstruction.
Hence it is best to avoid the inlay technique.
Placing the mesh on newly created midline is the
safest method as the mesh can be securely fixed
medially and laterally as well as avoid the chances
9. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1897
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of peritoneal intrusion. The rectus muscle on
either side lies on the surface of the mesh thereby
reducing the exposed area of the mesh
significantly.
Figure VII : (Polypropylene placed over the
newly created anterior abdominal wall extending
into the newly created retro rectus spaces on either
side and fixed to the lateral cut edges of the
anterior rectus sheath)
(Figure VII) The central portion of the mesh only
gets exposed to the subcutaneous tissues of the
anterior abdominal wall. The lateral edge of the
cut anterior rectus sheath serves as an excellent
site to fix the mesh on either side. Thus effectively
the mesh is spread all across the newly
createdaponeurotic tissue cover thereby aiding its
reinforcement.
Mesh being a foreign material, always elicits a
foreign body reaction leading to the development
of a seroma. These seromas are sterile to begin
with, but may develop infection at a later date.
Repeated aspirationof these seromas can lead to
disastrous complication of infection. Once a
hernia repair gets infected it leads to an absolute
failure of surgery necessitating removal of the
mesh. The best way to obviate this complication is
by using a negative suction drain at the time of
surgery. [9, 10] It prevents accumulation of tissue
fluid and blood at the operative site thereby
preventing hematomas and seromas. By virtue of
a vacuum created at the site of operation dead
space gets obliteratedquickly due to tissue
approximation.Absence of dead space prevents
fluid collection and enhances the healing process
as well. Negative pressure or vacuum
stimulatesthe growth of excellent granulation
tissue at the site of surgery. [11] A good volume
of granulation tissue leads to exuberant fibrosis
leading to the formation of thickand strong scar
tissue. The drain is kept till it has served its
purpose. There is no fixed time frame for removal
of drain. The amount of drain fluid depends on
every individual patient. The criteria of drain
removal followed in present case series was a
serous drain output of less than 20cc on 2
consecutive days.
The subcutaneous tissue was approximated with
absorbable suture material.After approximation a
saline lavage was given to the subcutaneous tissue
and mopped dry. Skin was approximated
specifically with staples. Skin suturing was
avoided as multiple suture puncture predisposes to
superficial skin infection leading to stitch
abscesses. These stitch abscesses at times can
prove to be detrimental to the repair. If undetected
or mistreated the infection from this source can
find its way up to the mesh thereby leading to
infection of mesh.Therefore it is asafe practice as
was followed in present study of doinga check
dressing after 72 hrs. There was redness and a
small collection in one of the patients which was
10. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1898
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detected and aggressively treated with complete
resolution without any complications.
The use of topical antibiotics has always been
criticized by researchers. However our experience
with the use of topical antibiotics was very
good.Topical use of injectable chloramphenicol
powder yielded excellent results with no wound
infection at all. Even in the solitary case which
was reported to be infected,therewas no purulent
collection but only a small volume of blood
stained fluid which was drained and resolved
immediately. The wound was classified as
infected only by virtue of redness at the surgical
site and not by virtue of any purulent collection.
Of the 15 patients operated 4 had a short duration
of ileus which resolved spontaneously. Ileus is
usual accompaniment of bowel handling at the
time of adhesiolysis.It is a safe practice to have a
Ryle’s tube in all patients especially those in
whom bowel handling has taken place.Ryle’s tube
can safely be removed after 24 hrs. One of the
patients developed severe exacerbation of COPD
warranting aggressive medical treatment.
Development of exacerbation of comorbidities can
serveas a deterrent to successful outcome in
incisional hernia repair.[12] Rigorous control and
monitoring of blood sugar levels,bronchodilators
in diabetics and COPD patients respectively is of
utmost importance.It is safeto keephigh risk
patients with comorbidities under observation for
48hrs in ICU inorder to prevent any untoward
event from developing.
The mean duration of stay in hospital in our study
was 6.2 days. The criteria for discharge from
hospital was based on absence of wound
complication, passage of stools and complete
control of comorbidities. It is safe to send the
patients home as soon as possible in order to
prevent development of resistant nosocomial
infections. At the time of discharge all patients
were to trained to use an abdominal corset. Every
patient was advised to use an abdominal corset for
a period of 12 weeks compulsorily.An abdominal
corset has many advantages in patients of midline
incisional hernia repair. It provides a firm counter
support to the repaired structures against intra-
abdominal forces. It causes excellent realignment
of subcutaneous tissues thereby leading to a
smooth contour of anterior abdominal wall. 12
weeks is enough a period for the process of
fibrosis to have begun followed by
commencement of maturation. Abdominal corset
greatly aids quick recovery or rehabilitation as it
provides a psychological feeling of a secured
support to the newly repaired abdominal wall. The
mean follow up in the present study was 16.7
months. None of the patients have developed a
recurrence till the last follow up as recorded in the
charts. Though cost implications were not studied
in the present study yet cost is an important factor
which deserves special attention especially in the
developing world. Tissue repair by itself has less
expenditure as compared to mesh repair. However
as the recurrence rate of pure tissue repair is high
it requires another surgery in the form of mesh
repair. [13] This puts a great strain on the
financial resources of the patient. Laparoscopic
repair is the costliest with no proven advantage.
Therefore a combination of tissue and mesh repair
is the most cost effective method for repair.
11. Dr.Ketan Vagholkar, Dr. Abhijit Budhkar JMSCR Volume 2 Issue 8 August 2014 Page 1899
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CONCLUSION
Based on the surgical outcome of our study we
advocate the technique of combination of
anatomical reconstruction of the anterior
abdominal wall using the rectus apparatus
alongwith mesh reinforcement for midline
incisional hernia.
ACKOWLEDGEMENTS
We would like to thank the Dr.Shirish Patil,
Dean of Dr.D.Y. Patil Medical College, Navi
Mumbai, India for allowing us to publish this case
series.
We would also like to thank Parth K. Vagholkar
for his help in typesetting the manuscript
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