Case #2: Mr. Lewis

Objective : 5

Taylor Vaughan

Doc, it’s really hard talking to a

complete strangerabout this, but I

think I might need Viagra

If it’s hardtalking to strangers,

sounds like wemay not need the

Viagra… Just talk tomore strangers

ObjectivesCategorize different types of

hernias

Describe management of reducible vs incarcerated hernias

Summarize causes and management of postoperative ileus

DefinitionsHernia – protrusion of organ/tissue

through wall defect

Incarcerated – unable to be reduced

Strangulated – blood supply to enclosed bowel has been compromised

Inguinal Hernias75% of all hernias

1/3 direct

2/3 indirect

Direct Inguinal HerniaBowel travels through abdominal

fascia → external inguinal ring

Medial to inf. epigastric vessels

More common in older individuals

Indirect Inguinal HerniaBowel travels through internal

ring → external ring

Lateral to inf. epigastric vessels

Via patent processus vaginalis

Management AlgorithmReducible

Asymptomatic

Observation

Symptomatic

Elective Repair

Emergent repair

Incarcerated

Exquisite tendernessPeritoneal signs

Repair700,000/yr in the US

Herniotomy – removal of hernia sac

-rrhaphy – hernia sac removal with defect pathway obliteration

-plasty – repair with autogenous or autologous material

Other Hernia Types

Ventral Hernias

Incisional – midline in people predisposed to poor wound healing

Umbilical – often congenital◦Observe unless >5yo or >2cm

Other Hernia Types

Femoral Hernias

Bulge below inguinal ligament

Female>Male 2:1

Commonly strangulate → Repair

Post Operative Ileus (POI)

“Loss of intestinal peristalsis in the absence of mechanical obstruction”

PathogenesisInhibitory neural reflexes

◦Increased sympathetic toneInflammation

◦Injury→macrophages→COX2/PG→ decreased intestinal contraction

Neurohumoral peptides◦NO, VIP, Sub P – inhibitory GI NTs

Opioids◦↑ resting tone, ↓ gastric motility, ↓

colonic propulsion

EvaluationIleus is often normal/physiologic

Abdominal XR ◦Rule out obstruction or foreign body

Vitals/Labs◦Rule out infection or correctable

electrolyte disturbance (K / Mg)

ManagementGentle diet advancement

Midthoracic epidural◦Blocks nociceptive afferents

NG Tube??

Chewing gum??

ManagementPeripherally acting opioid

antagonists◦Don’t effectively cross BBB◦Block mu-opioid efffects peripherally◦Maintains central effects… analgesia!

Methylnaltrexone (Relistor)

Almivopan (Entereg)

References Delaney, CP, Wolff, BG, Viscusi, ER, et al. Almivopan, for

postoperative ileus following bowel resection: a pooled analysis of Phase III studies. Ann Surg 2007; 245:355.

Holzer, P. Treatment of opioid-induced gut dysfunction. Expert opin investing drugs. 2007; 16:181.

Karthikesalingam, A, Markar, SR, Holt, PJ, et al. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010; 97:4.

UpToDate.com (abdominal wall hernias, groin hernias, postoperative ileus)

Viscusi, ER, Gan, TJ, Leslie, JB, et al. Peripherally acting mu-opioid receptor antagonists and postoperative ileus: mechanisms of action and clinical applicability. Anesth analg 2009; 108:1811.

Wikipedia (hernia, ileus)