bohomolets surgery 4th year lecture #2

LECTURE 2

ABDOMINAL WALL HERNIAS

National O. Bogomolets Medical University

Faculty Surgery Department N1Kyiv 2007

Prof. Kucher M.

A hernia 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.

INCIDENCE

No peritoneum sac - no hernia:

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


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


Umbilical hernias occur in the umbilicus (belly button). They are usually congenital hernias (present since birth)


Incisional hernias occur at the site of previous abdominal surgery

Inferior lumbar hernia of Petit

Superior lumbar hernia of Grynfellt-Lesshaft

The anterior perspecrive

The posterior perspecrive

TESTIS DESCENDING

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 hydroceleNormal scrotum

Can I get above it?

hydrocele Congenital hernia

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:

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

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.

Symptoms & signs

Protruding bulge Pain Discomfort Weakness

symptoms of Inguinal hernia:

Groin lump Groin pain Intestinal blockagereducible swellingritual of patient cough

Physical examination

DIFFERENTIALS• Epididymitis

• Hidradenitis Suppurativa

• Hydrocele

• Lymphogranuloma Venereum

• Testicular Torsion

Groin abscessHematomaLipomaLymphadenitisPseudoaneurysmSpermatoceleTumorUndescended or retracted testesVaricocele

US & Radiology

• With more than 20 million hernia repairs occurring annually worldwide, hernia repair is indeed the most common general surgical operation.

Inguinal hernia repairs

Open Nonprosthetic (Tension repair)Open Prosthetic (Tension-free)Laparoscopic TAPP or TEP (Tension-free)

Open Nonprosthetic: Bassini

Open Nonprosthetic: Shouldice

Open Prosthetic : Lichtenstein

М. М. КучерКучер

LaparoscopicLaparoscopicТАРРТАРР


ТАРРТАРР


ТАРРТАРР:: mesh fixation (tacking)esh fixation (tacking)


ТАРРТАРР: peritoneum closure: peritoneum closure

Prognosis : hernia recurrence • hernia recurrence rates after primary groin hernia repair :

from < 1% to almost 15%• after repair of recurrent groin hernia: < 3% of second

recurrence

• after incisional hernia repair may exceed 30%• closure under excessive tension• failure to exclude adjacent musculoaponeurotic defects• failure to identify and use an adequately strong

musculoaponeurotic margin• wound infection• inadequate collagen formation in the wound (malnutrition,

concomitant therapeutic administration of corticosteroids or antimetabolites)

• chronically high intraabdominal pressure

Long term randomized clinical trial of non mesh versus mesh repair of primary inguinal hernia

• Prospective studies and meta-analysis have demonstrated the increased recurrence rate with no mesh technique

• The 10 year cumulative hernia recurrence rate of

17% for non mesh and 1% for mesh repair

• Half of the recurrences after 3 years follow up

Van Veen Rat et al Br. J. Surg 2007; 94;505-10

Two meta-analyses (Memon 2003 & McCormack 2003)

Laparoscopic vs Open hernia repair

Both conclude that:• - lap hernia takes longer to perform• - lap hernia associated with less pain• - lap hernia ---- faster to return to normal activity• - lap hernia recurrence rates similar or lower• - lap hernia complication rare similar or lower

BUT SOME RARE SEVERE UNIQUE COMPLICATIONS in lap hernia


Hernia complicationsHernia complications

•InflammationInflammation•IncarcerationIncarceration•ObstructionObstruction•StrangulationStrangulation•TraumaTrauma•MalignancyMalignancy


if those organs if those organs cannot slide easily cannot slide easily

back into the back into the abdomen,the hernia abdomen,the hernia

is said to be is said to be irreducible. irreducible.

Irreducible hernias Irreducible hernias are often painful and are often painful and

can lead to can lead to complicationscomplications

Hernia complicationsHernia complications


if the intestine if the intestine becomes trapped becomes trapped in the hernia sack in the hernia sack

it is said to be it is said to be incarceratedincarcerated


if the neck of the if the neck of the hernia sack actually hernia sack actually

pinches off the supply pinches off the supply of blood to those of blood to those

organs which have organs which have become trapped inside, become trapped inside, the hernia is said to be the hernia is said to be

strangulatedstrangulated

Severe pain Fever Vomiting Gangrene


strangulation of strangulation of antimesenteric portion of antimesenteric portion of

the bowel (Richter’s hernia)the bowel (Richter’s hernia)No signs of obstruction!!!No signs of obstruction!!!

Stragulated herniaStragulated hernia

Maydl’s herniaMaydl’s hernia


strangulated herniastrangulated hernia is a medical emergency is a medical emergency

that requires immediate surgerythat requires immediate surgery

Intraoperative options

• Intestine viability• Kocher’s rule

Mayo umbilical hernia repair

Incision hernia

Incision hernia repair• Recurrence rates:

• 34-54% Non Mesh (Anthony,2000)

• 24 % Mesh (Luijendijk,2000)

Onlay placement

GORE-TEX DUALMESH

The biomaterial features two functionally distinct surfaces: a closed structure surface for reduced tissue attachment and a macroporous structure surface for faster tissue attachment.

sublay/inlay placement

VYPRO mesh is placed preperitoneally as a sublay

Direct contact between the mesh and intraperitoneal structures must be

avoided by using intact peritoneum

PROLENE MESH: major comlication

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

Ideal hernia mesh• Remains strong and supple• Does not shrink• Incorporates rapidly to the abdominal wall• Provides for permanent repair• Does nor adhere to viscera• Does nit become infected• Not carcinogenic or allergenic• Causes no pain or discomfort• Easy to handle• inexpensive

Incision hernia repair

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.

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.

New biological mesh

• Allogenic (cadaveric)

• Xenogenic (bovine or porcine)

– Surgisis – laminates of porcine collagen from small intestine submucosa

bohomolets surgery 4th year lecture #2

Health & Medicine