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A presentation of different abdominal Hernias.pptx

The document provides a comprehensive overview of hernias, including their definitions, types, risk factors, and management. It details the classification, diagnosis, surgical repair techniques, and potential complications associated with hernias, particularly inguinal and femoral hernias. The importance of a tailored approach for individual cases and the significance of proper surgical technique in minimizing recurrence and complications is emphasized.

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Hernias Nabin Paudyal
Introduction • Abdominal core: circumferential soft tissues of the diaphragm superiorly, pelvic floor inferiorly, abdominal wall and flank anterolaterally excluding abdominopelvic viscera • Hernia management is an integral component of maintaining abdominal core health • Hernia Latin word Rupture • Defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls • Occurs at sites at which the aponeurosis and fascia are not covered by striated muscle.
• Neck innermost aponeurotic layer • Sac Lined by peritoneum • No relationship between area of the defect and size of the sac
Sequalae • Reducible Irreducible/ incarcerated Strangulation • Adhesion between contents of the hernia and peritoneal lining of the sac can provide a tethering point that traps the hernia contents and predisposes to intestinal obstruction and strangulation. • In Richter hernia Small portion of the antimesenteric wall is trapped within the hernia it is an example of hernia in which strangulation can occur without presence of intestinal obstruction.
• External hernia Protrudes through all layers of abdominal wall • Internal hernia Protrusion through a defect in the peritoneal cavity • Interparietal hernia Hernial sac is contained within musculoaponeurotic layer of abdominal wall
6 Principle of hernia repair Exploration and identification of sac Reduction of content , removal of non-viable content and repair excision and closure of peritoneal sac Reapproximation of walls of hernia if possible Permanent reinforcement : suture, mesh or tissue repair Tension free
Inguinal hernias
Inguinal hernia • Direct and indirect • Pantaloon Both component present • Incidence • 5% of population develop abdominal wall hernia • 75% of all abdominal wall hernia are inguinal • 2/3rd  Indirect hernia (MC hernia) • Risk percentage • Men: Women 25:1 • In men  Indirect: Direct hernia 2:1 • In women Indirect hernia is the MC type of hernia in women • Femoral and umbilical hernia : female to male ratio  10:1 (Femoral); 2:1 (umbilical) • 10% of women and 50% of men who have femoral hernia will develop inguinal hernia
• Strangulation occurs in only 1-3% of groin hernias • Most strangulated hernias are indirect inguinal hernias • Femoral hernias have highest rate of strangulation (15-20%) of all hernias • Presence of arterial aneurysm increases the risk of inguinal hernia. • Hence all femoral hernias are repaired at the time of discovery.
Boundary of inguinal canal
Boundary of deep inguinal ring
Contents of spermatic cord • Cremasteric muscle • Testicular artery • Accompanying veins • Genital branch of genitofemoral N • Vas deferens • Cremasteric vessels • Lymphatics • Processus vaginalis
Iliopubic tract • Most important structure in hernia repair • Lateral to internal inguinal ring and along the portion of iliopubic tract staples and tacks are not applied because following nerves are located inferior to iliopubic tract • Femoral • Lateral femoral cutaneous • Genitofemoral nerves
Preperitoneal space • Nerves in preperitoneal space Lateral femoral cutaneous N. (L2-L3), genitofemoral N (L2) • A and V in preperitoneal space Deep circumflex iliac A and V • During lap hernia repair, one must dissect above iliopubic tract to avoid injury to these vessels. • Vas deferens Courses caudal to cephalic direction and medial to lateral to join spermatic cord at deep inguinal ring
Diagnosis of hernia
Diagnosis • Bulge in the groin • Pain or vague discomfort in the region; 1/3rd symptomless • Extremely painful hernia strangulation or incarceration • Paresthesia related to compression or irritation of the inguinal nerves • Examination of hernia • Inspection • Palpation • Look for asymmetry and bulge • Cough/ positive Valsalva • Fingertip placement at the site of hernia • N.B. distinction of indirect and direct hernia is not critical because repair is approached in the same way regardless of the type of hernia
Classification of hernia • European Hernia Society classification
Nyhus classification • How does inguinal canal maintain its integrity? • Obliquity of canal Flap valve • Roof to floor approximation of IOM  Shutter valve • Cremasteric muscle contraction causes plugging of superficial inguinal ring Ball valve • V-shaped superficial inguinal ring preserves integrity Slit valve • Hormones.
Management • Nonoperative treatment • Strategy of watchful waiting is safe for older patients with asymptomatic or minimally symptomatic inguinal hernias • When operation is done, operative risks and complication risks are no different from patients undergoing operative repair. • Adopted only for men. In women, if femoral hernia Operative intervention • In patients with non operative hernia repair • Use of truss is recommended; spring truss is recommended to be used. • 30% of patients with truss report symptom control
Operative repair of inguinal hernia • Anterior repair • Most common operative approach • TENSION FREE repair is now standard • N.B. When an indirect hernia is present, the hernial sac is located deep to the cremaster muscle and anterior and superior to the spermatic cord structures • Sac is dissected up to level of internal inguinal ring • Sac can be: • Opened and examined for contents • Mobilized and placed into peritoneal cavity • Ligated at the base of the sac • Mesh prosthesis placed. • Tissue repair • Cases in which mesh prosthesis repair is contraindicated, we do tissue repair • Used in strangulated hernia repair as mesh fixation is not done in such cases • Options for tissue repair include Iliopubic tract repair, Shouldice, Bassini, McVay repair, Darn repair, Halsted repair. [@MB-DISH] • Laparoscopic and Preperitoneal repair • TAPP, TEP, e-TEP.
Tissue repair • Tissue repair has high rate of recurrence. • Iliopubic tract repair • Approximates transversus abdominis aponeurotic arch to iliopubic tract with interrupted sutures • Repair begins at the pubic tubercle and extends laterally past the internal inguinal ring.
• Shouldice repair • Multilayer imbricated repair of the posterior wall of the inguinal canal with continuous running suture • Initial suture layer  transversus abdominis aponeurotic arch to iliopubic tract (T--- IT ) • Second layer Internal oblique and transversus abdominis and aponeurosis are sutured to inguinal ligament (T---IL) • HAS VERY LOW RATE OF RECURRENCE. • Bassini repair • Transversus abdominis and internal oblique aponeurosis or conjoint to the inguinal ligament • Approach to non anatomic hernia repair • McVay repair (Cooper ligament repair) • Used for • Direct hernia • Large indirect hernia • Recurrent hernia • Femoral hernia • Transversus abdominis aponeurosis is approximated to Cooper ligament and iliopubic tract using interrupted suture (@ T—CI) • Relaxing incision is given • For femoral hernias
Shouldice repair
McVay repair
Bassini repair [Non-anatomic repair]
Tension-free anterior inguinal hernia repair • Dominant method of hernia repair now • Lichtenstein tension free mesh repair method • Various modifications available • Original Lichtenstein approach • Plug and patch technique (of Gilbert) • Sandwich technique • Certain highlights of original Lichtenstein approach • Fixation of the mesh to the pubic tubercle itself should be avoided, but to the shelving edge of the inguinal ligament • Overlapping of the mesh should be by at least 15 mm
Plug and patch repair of (Gilbert) • Cone-shaped plug of polypropylene mesh is inserted into the internal inguinal ring like an upside-down umbrella. • Occlusion of the hernial site occurs (plug) • Overlying mesh is placed (patch)
Sandwich technique for repair • Involves use of bilayered device with three polypropylene components • First layer underlay patch Posterior repair similar to laparoscopic approach • Connector similar to plug • Third layer Onlay patch that covers the posterior inguinal floor. Stoppa-Rives repair • Sub umbilical midline incision to place large prosthetic mesh into preperitoneal space • Blunt dissection is used to create a space extra peritoneally from prevesical space to lateral pelvic brim • Advantage in distributing abdominal pressure across a broad area to retain mesh in proper location • Used for large, recurrent or bilateral hernias
Some important repair techniques
Laparoscopic hernia repair
Laparoscopic repair • This approach provides mechanical advantage of placing a large mesh behind defect, covering myopectineal orifice and using natural forces to disperse intraabdominal pressure over larger area to support mesh in place • 0.3% risk of vascular/ visceral injury • Techniques • Totally extraperitoneal approach (TEP) • Transabdominal preperitoneal approach (TAPP) • Extended TEP (e-TEP)
Myo pectineal orifice of Fruchaud • Located along the inferomedial aspect of anterior abdominal wall • Encompasses deep inguinal ring, inguinal triangle, portal inferior to inguinal ligament that transmits femoral neurovascular structures • Inguinal ligament travels diagonally through the MPO dividing into 2 parts. • Content: • Round ligament (females) • Spermatic cord (males) • Surgical importance • MPO is a common site of herniation
• TEP approach • Dissection begins in preperitoneal space • Balloon dissector used • Working space is more limited and there is a possibility of peritoneal injury • If there is tear in peritoneum during TEP approach, there is conversion to TAPP approach. • Hence knowledge of transabdominal technique is essential in performing lap hernia repair. • Steps • Infraumbilical incision • Anterior rectus sheath incised • Ipsilateral rectus abdominis retracted laterally • Retro-rectus space created • Dissecting balloon inserted deep to posterior rectus sheath, advanced to pubic symphysis and inflated • Space is insufflated and additional trocars placed • The inferior epigastric vessels are identified that serve as a landmark. • Nerves that can be damaged Femoral branch of genitofemoral N, LFCN of thigh
• TAPP approach • Infraumbilical incision given to access peritoneal cavity directly • Two 5-mm ports placed lateral to inferior epigastric vessels at level of umbilicus • Peritoneal flap created extending from median umbilical fold to ASIS • Rest steps as per TEP • Hernia reduction • Small hernias reduces itself • Large sac is divided with cautery, near internal inguinal ring leaving distal sac in situ, proximal peritoneal sac is closed with loop ligature/ clips. • Mesh deployment and fixation • 12 cm X 14 cm polypropylene mesh used • Covers direct, indirect, femoral
Measurements for placing polypropylene mesh • Dissect peritoneum 4 cm off cord structures • Fix mesh at least 2 cm above the hernia defect Structures in which the mesh is fixed Medially Cooper ligament Anteriorly Posterior of the rectus abdominis muscle and transversus abdominis Laterally Iliopubic tract Inferiorly is nerve  (within the triangle of doom) hence inferior tacker is not used
Complications of inguinal hernia repair Recurrence • No significant differences amongst various techniques for repair • Risk of death is related to the comorbid conditions of the patient • Type of anesthesia doesn’t affect the recurrence rate of hernia • Recurrence rate of hernia 1.7-10%. Tension free repair have low hernia recurrence rate than tissue repair • Open and laparoscopic have similar rate of hernia recurrence • Danish Hernia data base Lichtenstein mesh repair hernia recurrence 25% • Shouldice repair has highest rate of recurrence • Approximately 50% of recurrence occurs within 3 years after primary repair • No difference in recurrence between TAPP and TEP repair.
Femoral hernia
Boundary of femoral canal • Anterior: Inguinal ligament • Posterior: Pectineal ligament • Lateral: Thin septum separating it from femoral vein. • Medial: Gimbernat’s ligament (lacunar ligament)
Boundary of femoral hernia • Superiorly Iliopubic tract • Inferiorly Cooper ligament • Laterally  Femoral vein • Medially Junction of iliopubic tract and Cooper ligament (arcuate ligament)
• 50% of men with femoral hernia will have associated direct inguinal hernia Repairing the femoral hernia • Can be cooper ligament repair/ preperitoneal approach/ laparoscopic approach. • Dissection and repair of hernial sac • Obliteration of defect in femoral canal • 2 ways to approximate • Iliopubic tract and Cooper ligament approximation • Prosthetic mesh placement • Mesh is not used in cases with strangulation • All femoral hernias should be repaired. • Recurrence • 2% after primary repair • 10% after re-repair • 3 types of repair is done in femoral hernia • Mc Evedy repair (High-inguinal) • Lothessian repair (Inguinal) • Lockwood repair (Low-inguinal) • 3 types of femoral hernia • Narath hernia lies beneath femoral vessels • Languier’s hernia Arises from gap in lacunar ligament (usually strangulated) • Cloquet hernia underneath the fascia of pectineus muscle
Lockwood repair • Low or infra-inguinal approach • Incision given directly over swelling • Sac is carefully dissected out • Sac ligated at neck, excised and hernia is repaired • Inguinal ligament sutured to cooper’s ligament – obliterates femoral ring • Indicated for uncomplicated hernia
Lotheissein • Trans inguinal approach • Incision 2cm above inguinal ligament; inguinal canal is opened • Hernial sac visualized • Excision of sac • Preferred when there is strangulated femoral hernia
Mc Evedy • High inguinal approach • Skin incision given 3 cm above pubic tubercle running laterally • Preferred in emergency setting when strangulation is suspected allowing better access to and visualization of bowel for possible resection • [Video demonstration of Mc Evedy incision and operation]
Midline Abdominal Extraperitoneal Femoral Hernioplasty (Henry Procedure) • Procedure of choice now for femoral hernia • Doesn’t damage the transversalis fascial floor
Some caveats of hernia • Recurrent hernias require placement of mesh for successful repair • Recurrent hernia after anterior repair require either laparoscopic repair/ posterior mesh placement • For bilateral inguinal hernia Giant prosthetic repair (Stoppa repair) or laparoscopic repair for simultaneous repair of both hernias
Complications of hernia repair
Complications of hernia repair • Increased scarring and disturbed anatomy with hernia recurrence can result in an inability to identify important structures at operation. Hence different approach for recurrent hernias is recommended. • 10% overall complication of hernia • A. Surgical site infection • 1-2% of open repair • No recommendation for use of antimicrobials prior surgery • Patients with ASA 3 status cefazolin 2 to 3 g IV 30-60 minutes before the incision • In allergic patients Clindamycin 900 mg IV. • Superficial SSI open the incision, local wound care, secondary intention healing • Deep SSI Removal of the mesh • Treat any skin condition prior inguinal repair (if exists)
B. Nerve injuries and Chronic pain syndromes • Most commonly affected nerves in open repair ilioinguinal N, genital branch of GF N, iliohypogastric N. • Most commonly affected nerves in lap repair LFC nerve, GF nerve. • Neuralgias that occur may be: • Transient: Self-limited, sensory involvement • Persistent: pain and hyperesthesia, exacerbated by hyperextension of the hip and relieved by flexion of the thigh. • Chronic postherniorrhaphy pain: Pain persisting more than 3 months after operation • Strategies of routine nerve division have not been associated with reduction in chronic groin pain. • Division of ilioinguinal N is associated with significantly more sensory disturbances. • Management: • Identify and preserve all 3 N • Avoid direct fixation to Pubic tubercle • Minimal disruption of cremasteric muscle • Use of interrupted suture fixation superiomedially
• Management of residual neuralgia • NSAIDS • Analgesics • Local anesthetics • Surgical approach to groin pain • Local intervention Mesh excision, Tack excision, Mesh debulking • Nerve-related intervention Neurectomy
c. Ischemic orchitis and testicular atrophy • Occurs usually from thrombosis of small veins of pampiniform plexus within spermatic cord • Results in venous congestion Testicular swelling 2-5 days after surgery testicular atrophy • Caused by unnecessary dissection within spermatic cord • Especially while dissection of distal portion of large hernial sac • Hence for large hernias, posterior approach is preferred • Ischemic orchitis may lead to testicular atrophy • Incidence of ischemic orchitis increased by factor of 3-4 with each subsequent hernia repair. • Hence ischemic orchitis occurs while doing recurrent hernia repair • Management NSAIDS and anti- inflammatory
d. Injury to vas deferens and viscera • Unusual • Usually in management of sliding hernia when there is failure to recognize presence of intraabdominal viscera in hernia sac e. Inguinal hernia recurrence • Caused by technical factors like excessive tension during hernia repair missed hernias failure to include an adequate musculoaponeurotic margin improper mesh size improper mesh placement failure to close patulous hernial ring intra abdominal pressure chronic cough deep infections poor collagen formation in wound Direct hernias recur more Femoral hernias may be present in cases with Inguinal hernia recurrence. Must be investigated.
Management of recurrent inguinal hernias • Use prosthetic mesh • Choose different OT approach • Avoid dissection through scar tissue • Recurrences can be best managed by placing second prosthesis through different approach • Rate of recurrence is similar in both laparoscopic and open approach • Re-recurrence rates • 4-5% in first 24 months • 7.5% at 5 years
Ventral hernias
Definition and incidence • A ventral hernia is protrusion through the anterior abdominal wall • May be spontaneous or acquired • Acquired hernias Incisional hernias • Diastasis recti stretch in Linea alba resulting in bulge at the medial margin of rectus muscle • Unless significantly symptomatic Don’t repair • Incisional hernia 15% • Umbilical hernia and epigastric hernia 10% • Incisional hernias are twice common in ladies • Causes • Obesity • Old age • Male • Sleep apnea • Emphysema • Prostatism • Wound infection
• Incidence of ventral hernia and surgery incision types • Midline 10.5% • Transverse 7.5% • Paramedian 2.5% • Ventral hernias are to be repaired when discovered. • Classification of ventral hernia • Umbilical hernia • Epigastric hernia • Incisional hernia
Umbilical hernia
• Umbilical hernias in infants are congenital. • Most spontaneously close by 2 years • Persistent hernias after 5 years of age require surgery • Umbilical hernias in adults are acquired • More in women • Indications for repair • Large hernia • Incarceration • Uncontrollable ascites • Thinning of overlying skin • Mayo’s repair  vest over pants • Involves 2-layered imbrication of superior and inferior fascial edges • Mayo’s repair has recurrence of 30% Not done nowadays Defect size < 3cm Primary repair >3 cm Mesh repair
Umbilicus: adult vs neonate
Epigastric hernia
• 3-5% of hernias • 2-3 times more common in men • Usually in location between xiphoid process and umbilicus (5 to 6 cm within) • Feature is to produce pain out of proportion • Pain is caused by incarceration of preperitoneal fat • Repair involves: • Excision of preperitoneal tissue • Simple closure of fascial defect • Epigastric hernias are repaired anteriorly
Incisional hernia
• Most challenging and difficult • Occurs as a result of excessive tension and inadequate healing of previous incisions • Hernias enlarge over time, cause pain, bowel obstruction, incarceration and strangulation • Risk factors • Obesity • Advanced age • Malnutrition • Ascites • Pregnancy • COPD • DM • Immunosuppressants • SSI • Loss of domain hernias Abdominal contents can no longer stay in the cavity and protrude • With loss of domain hernias, natural rigidity of abdominal wall becomes compromised and abdominal musculature is retracted. • Results of loss of domain • Respiratory dysfunction • Bowel edema • Stasis of splanchnic circulation • Urinary retention • Constipation
• Width of the hernia and presence of contamination are the 2 variables associated with wound morbidity and hernia recurrence. • Hernia classification using width and wound class alone
Management of ventral hernia • Primary done is done when • Hernia is <3 cm diameter • Viable surrounding tissue • Hernia created by technical error in previous operation • Prosthesis (E.g. Mesh) • Hernia > 3 cm in diameter • Prosthetic materials used for hernia repair • Permanent synthetic materials • Characteristics of an ideal mesh • Chemically inert • Resistant to mechanical stress • Sterilizable • Compliant • Non carcinogenic • Non inflammatory • Hypoallergenic • [@ CRS-CNN-H]
• 1.Permanent synthetic mesh • Consider position of the mesh • Presence of risk of infection • Mesh can be classified on the basis of • Weight of material • Pore size (Macro/ microporous) • Water angle (hydrophobic/ hydrophilic) • Whether adhesive barrier is present/not • Choice of mesh • Extraperitoneal microporous, unprotected mesh, prolene/polyester mesh • Intraperitoneal Various options are available • [See next slide] Mesh Weight Lightweight < 40g/m2 Medium weight 40-60 g/m2 Intermediate weight 60-75 g/m2 Heavy weight >75 g/m2 Lightweight vs heavyweight Lightweight is favored When recurrence is the issue Heavyweight is favored Bacterial contamination Large pore synthetic mesh is used [ animal studies] Complex ventral hernias Polyester mesh (microporous mesh)
• 2. Biological mesh • Nonsynthetic, natural tissue mesh • Classified as • Source Human/ Porcine/ Bovine • Postharvest processing Cross-linked/non-cross-linked • Sterilization techniques Gamma radiation, Ethylene oxide gas • Contain acellular collagen make it suitable to be used in infected/ contaminated cases. • Function best when used as fascial reinforcement rather than bridge or interposition repair • 3. Absorbable synthetic mesh • Polyglactin used to construct absorbable synthetic mesh • Mesh can be placed in any plane but typically with soft tissue covering mesh anteriorly • Can be used in contaminated complex ventral hernia repair
Operative techniques in Ventral Hernia
• Sublay may be further of • Rectorectus (Rectomuscular) • Preperitoneal • Intraperitoneal • Highly desirable to place mesh beneath the fascia. • 1. Intraperitoneal mesh placement • Composite mesh • 4 cm fascial- mesh overlap • Interrupted mattress suture • Mesh placement may be • Onlay • Interposition (Inlay) • Sublay
• 2. Myofascial releases • Fascial layer is separated from the muscular layer in the abdominal wall • Basic principle • Abdominal wall and rectus muscle are bounded by several different myofascial compartment • By releasing one or more fascial bundles, advancement of the rectus muscle to the midline is possible • Each of these procedures creates a local advancement flap of the rectus muscle • 3. Posterior rectus sheath incision with retromuscular mesh placement [Stoppa repair] • A prosthetic mesh is placed in extraperitoneal position in preperitoneal space or retro rectus position • Mesh placed on top of posterior rectus sheath or peritoneum • Mesh extends 5-6 cm beyond superior and inferior borders of the defect
4. Component separation Posterior component separation • Also called as transversus abdominis release • Prerequisites • Tobacco free 1 month prior and 2 months after surgery • Albumin > 3.5 g/dl • HbA1C <7.0 • Pre-habilitation, 30 mins of walk per day • BMI < 35 Steps of posterior component separation 1. Incision and adhesiolysis 2. Packing of content 3. Incision of posterior rectus sheath 4. Retrorectus dissection 5. Transversus abdominis release 6. Retromuscular dissection 7. Posterior rectus closure (Zip sign) 8. Patch with Vicryl mesh 9. TAP block 10. Mesh deployment 11. Closure of midline 12. Skin closure
Anterior component separation • Involves separating the lateral muscle layer of the abdominal wall to allow their advancement • Anterior component separation done on both sides allow a mobilization of 20 cm • Too lateral advancement can lead to lateral bulging or lateral herniation Steps of anterior component separation • Raise large subcutaneous flap above EOM fascia • Flaps retracted laterally past linea semilunaris • Preserve perforators to SC flaps • Relaxing incision is given 2 cm lateral to Linea semilunaris on lateral EO aponeurosis superiorly from subcostal margin to pubis • Blunt separation of EOM from IOM
Some unusual hernias a. Spigelian hernias • Hernia between rectus muscle and semilunar line • Caused by absence of posterior rectus fascia. • Hernias are often interparietal with hernia sac dissecting posterior to the EO aponeurosis • Small hernias (1-2 cm) • 4th to 7th decade • USG/CT based diagnosis • Repaired by primary/ mesh repair • Open/ Laparoscopic technique can be used b. Obturator hernia • Patients present with evidence of compression of the obturator nerve which causes pain over anteromedial aspect of the thigh (Howship-Romberg sign) • Pain relieved by thigh flexion • Bowel obstruction is present • CT based diagnosis • Repaired by: Posterior approach • Hernia reduced • Preperitoneal fat pad within canal reduced • Obturator foramen is repaired with prosthetic mesh.
c. Lumbar Hernia • Occur in region of posterior abdominal wall. MC Male, left side • May occur through superior and inferior lumbar triangle • Superior lumbar triangle (Grynfelt triangle) herniation is more common • Cause: Weakness in lumbodorsal fascia • Lumbar hernia doesn’t strangulate • Repaired by mesh placement which is sutured beyond the margins of the hernia (Dowd’s operation) • Grynfelt triangle: Bounded by (@ 12 PI) • 12th rib • Paraspinal muscles • Internal oblique muscle • Petit triangle: Bounded by (@ LIE) • Latissimus dorsi • Iliac crest • EOM
Loss of domain hernias • Massive hernias in which the herniated contents cannot be replaced into the peritoneal cavity • Types: • With pre-operative contamination • Without pre-operative contamination • Also classified as • Small hernial defect [ t/t PPP] • Massive hernial sac [t/t PTFE dual mesh] Management • Careful pre-op evaluation • Follow pre-requisites for component separation • For large hernias staged approach using PTFE dual mesh and lateral retraction of abdominal wall musculature is done • Initial stage reduction of hernia, placement of large PTFE dual mesh, suture mesh to fascial edge • Subsequent stage serial excision of the mesh until fascia can be approximated • Finally, mesh completely excised and fascia reapproximated by component separation and biologic underlay patch
Other management technique of LOD hernias
Parastomal hernia • Incidence of stomal hernia is more for colostomies and is approximately 50% • Routine repair of parastomal hernias is not recommended • Indications • Bowel obstruction • Problems with pouch fit • Cosmetic issues • Repair approaches • Primary fascial repair • Stoma relocation • Prosthetic repair 1. Primary fascial repair hernia reduction and fascial reapproximation through peristomal incision. High recurrence rate 2. Prosthetic repair (using mesh) • Has excellent long term results with lower hernia recurrence. • Complications • Erosion • Obstruction • Approach • Onlay • Intraabdominal / Intraperitoneal • Retrorectus
Techniques of parastomal hernia repair • Sugar baker procedure (Mesh flap) • Mesh placed intraperitoneally • Stoma placed as flat sheet/ keyhole fashioned around the stoma • Lateralize the stoma as it exits the abdomen • Rectomuscular repair (keyhole mesh repair) • Laparotomy performed • Stoma taken down • Resited to contralateral abdomen • Posterior component separation done • Large mesh placed in retromuscular area to cover old stoma site, new midline incision and reinforce new stoma site • Stoma brought out through keyhole incision in mesh and matured.
Miscellaneous information • Seroma formed after mesh placement should be extracted only after 6-8 weeks. Drain placement can be done to reduce seroma formation. • Mesh infection: • 2 types of presentation • Acute with sepsis • Chronic indolent infection • Acute cases • Admission • IV antibiotics • Early debridement and mesh removal • Chronic cases • Per cutaneous drainage of fluid • Antibiotic suppression • CT scan to assess resolution of fluid  if low volume of fluid drain is removed
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A presentation of different abdominal Hernias.pptx

  • 1.
  • 2.
    Introduction • Abdominal core:circumferential soft tissues of the diaphragm superiorly, pelvic floor inferiorly, abdominal wall and flank anterolaterally excluding abdominopelvic viscera • Hernia management is an integral component of maintaining abdominal core health • Hernia Latin word Rupture • Defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls • Occurs at sites at which the aponeurosis and fascia are not covered by striated muscle.
  • 3.
    • Neck innermost aponeuroticlayer • Sac Lined by peritoneum • No relationship between area of the defect and size of the sac
  • 4.
    Sequalae • Reducible Irreducible/incarcerated Strangulation • Adhesion between contents of the hernia and peritoneal lining of the sac can provide a tethering point that traps the hernia contents and predisposes to intestinal obstruction and strangulation. • In Richter hernia Small portion of the antimesenteric wall is trapped within the hernia it is an example of hernia in which strangulation can occur without presence of intestinal obstruction.
  • 5.
    • External herniaProtrudes through all layers of abdominal wall • Internal hernia Protrusion through a defect in the peritoneal cavity • Interparietal hernia Hernial sac is contained within musculoaponeurotic layer of abdominal wall
  • 6.
    6 Principle of herniarepair Exploration and identification of sac Reduction of content , removal of non-viable content and repair excision and closure of peritoneal sac Reapproximation of walls of hernia if possible Permanent reinforcement : suture, mesh or tissue repair Tension free
  • 7.
  • 8.
    Inguinal hernia • Directand indirect • Pantaloon Both component present • Incidence • 5% of population develop abdominal wall hernia • 75% of all abdominal wall hernia are inguinal • 2/3rd  Indirect hernia (MC hernia) • Risk percentage • Men: Women 25:1 • In men  Indirect: Direct hernia 2:1 • In women Indirect hernia is the MC type of hernia in women • Femoral and umbilical hernia : female to male ratio  10:1 (Femoral); 2:1 (umbilical) • 10% of women and 50% of men who have femoral hernia will develop inguinal hernia
  • 9.
    • Strangulation occursin only 1-3% of groin hernias • Most strangulated hernias are indirect inguinal hernias • Femoral hernias have highest rate of strangulation (15-20%) of all hernias • Presence of arterial aneurysm increases the risk of inguinal hernia. • Hence all femoral hernias are repaired at the time of discovery.
  • 11.
  • 12.
    Boundary of deepinguinal ring
  • 14.
    Contents of spermatic cord •Cremasteric muscle • Testicular artery • Accompanying veins • Genital branch of genitofemoral N • Vas deferens • Cremasteric vessels • Lymphatics • Processus vaginalis
  • 15.
    Iliopubic tract • Mostimportant structure in hernia repair • Lateral to internal inguinal ring and along the portion of iliopubic tract staples and tacks are not applied because following nerves are located inferior to iliopubic tract • Femoral • Lateral femoral cutaneous • Genitofemoral nerves
  • 23.
    Preperitoneal space • Nervesin preperitoneal space Lateral femoral cutaneous N. (L2-L3), genitofemoral N (L2) • A and V in preperitoneal space Deep circumflex iliac A and V • During lap hernia repair, one must dissect above iliopubic tract to avoid injury to these vessels. • Vas deferens Courses caudal to cephalic direction and medial to lateral to join spermatic cord at deep inguinal ring
  • 25.
  • 26.
    Diagnosis • Bulge inthe groin • Pain or vague discomfort in the region; 1/3rd symptomless • Extremely painful hernia strangulation or incarceration • Paresthesia related to compression or irritation of the inguinal nerves • Examination of hernia • Inspection • Palpation • Look for asymmetry and bulge • Cough/ positive Valsalva • Fingertip placement at the site of hernia • N.B. distinction of indirect and direct hernia is not critical because repair is approached in the same way regardless of the type of hernia
  • 27.
    Classification of hernia •European Hernia Society classification
  • 28.
    Nyhus classification • Howdoes inguinal canal maintain its integrity? • Obliquity of canal Flap valve • Roof to floor approximation of IOM  Shutter valve • Cremasteric muscle contraction causes plugging of superficial inguinal ring Ball valve • V-shaped superficial inguinal ring preserves integrity Slit valve • Hormones.
  • 30.
    Management • Nonoperative treatment •Strategy of watchful waiting is safe for older patients with asymptomatic or minimally symptomatic inguinal hernias • When operation is done, operative risks and complication risks are no different from patients undergoing operative repair. • Adopted only for men. In women, if femoral hernia Operative intervention • In patients with non operative hernia repair • Use of truss is recommended; spring truss is recommended to be used. • 30% of patients with truss report symptom control
  • 31.
    Operative repair ofinguinal hernia • Anterior repair • Most common operative approach • TENSION FREE repair is now standard • N.B. When an indirect hernia is present, the hernial sac is located deep to the cremaster muscle and anterior and superior to the spermatic cord structures • Sac is dissected up to level of internal inguinal ring • Sac can be: • Opened and examined for contents • Mobilized and placed into peritoneal cavity • Ligated at the base of the sac • Mesh prosthesis placed. • Tissue repair • Cases in which mesh prosthesis repair is contraindicated, we do tissue repair • Used in strangulated hernia repair as mesh fixation is not done in such cases • Options for tissue repair include Iliopubic tract repair, Shouldice, Bassini, McVay repair, Darn repair, Halsted repair. [@MB-DISH] • Laparoscopic and Preperitoneal repair • TAPP, TEP, e-TEP.
  • 32.
    Tissue repair • Tissuerepair has high rate of recurrence. • Iliopubic tract repair • Approximates transversus abdominis aponeurotic arch to iliopubic tract with interrupted sutures • Repair begins at the pubic tubercle and extends laterally past the internal inguinal ring.
  • 33.
    • Shouldice repair •Multilayer imbricated repair of the posterior wall of the inguinal canal with continuous running suture • Initial suture layer  transversus abdominis aponeurotic arch to iliopubic tract (T--- IT ) • Second layer Internal oblique and transversus abdominis and aponeurosis are sutured to inguinal ligament (T---IL) • HAS VERY LOW RATE OF RECURRENCE. • Bassini repair • Transversus abdominis and internal oblique aponeurosis or conjoint to the inguinal ligament • Approach to non anatomic hernia repair • McVay repair (Cooper ligament repair) • Used for • Direct hernia • Large indirect hernia • Recurrent hernia • Femoral hernia • Transversus abdominis aponeurosis is approximated to Cooper ligament and iliopubic tract using interrupted suture (@ T—CI) • Relaxing incision is given • For femoral hernias
  • 34.
  • 35.
  • 36.
  • 38.
    Tension-free anterior inguinalhernia repair • Dominant method of hernia repair now • Lichtenstein tension free mesh repair method • Various modifications available • Original Lichtenstein approach • Plug and patch technique (of Gilbert) • Sandwich technique • Certain highlights of original Lichtenstein approach • Fixation of the mesh to the pubic tubercle itself should be avoided, but to the shelving edge of the inguinal ligament • Overlapping of the mesh should be by at least 15 mm
  • 40.
    Plug and patchrepair of (Gilbert) • Cone-shaped plug of polypropylene mesh is inserted into the internal inguinal ring like an upside-down umbrella. • Occlusion of the hernial site occurs (plug) • Overlying mesh is placed (patch)
  • 41.
    Sandwich technique forrepair • Involves use of bilayered device with three polypropylene components • First layer underlay patch Posterior repair similar to laparoscopic approach • Connector similar to plug • Third layer Onlay patch that covers the posterior inguinal floor. Stoppa-Rives repair • Sub umbilical midline incision to place large prosthetic mesh into preperitoneal space • Blunt dissection is used to create a space extra peritoneally from prevesical space to lateral pelvic brim • Advantage in distributing abdominal pressure across a broad area to retain mesh in proper location • Used for large, recurrent or bilateral hernias
  • 44.
  • 46.
  • 47.
    Laparoscopic repair • Thisapproach provides mechanical advantage of placing a large mesh behind defect, covering myopectineal orifice and using natural forces to disperse intraabdominal pressure over larger area to support mesh in place • 0.3% risk of vascular/ visceral injury • Techniques • Totally extraperitoneal approach (TEP) • Transabdominal preperitoneal approach (TAPP) • Extended TEP (e-TEP)
  • 48.
    Myo pectineal orificeof Fruchaud • Located along the inferomedial aspect of anterior abdominal wall • Encompasses deep inguinal ring, inguinal triangle, portal inferior to inguinal ligament that transmits femoral neurovascular structures • Inguinal ligament travels diagonally through the MPO dividing into 2 parts. • Content: • Round ligament (females) • Spermatic cord (males) • Surgical importance • MPO is a common site of herniation
  • 50.
    • TEP approach •Dissection begins in preperitoneal space • Balloon dissector used • Working space is more limited and there is a possibility of peritoneal injury • If there is tear in peritoneum during TEP approach, there is conversion to TAPP approach. • Hence knowledge of transabdominal technique is essential in performing lap hernia repair. • Steps • Infraumbilical incision • Anterior rectus sheath incised • Ipsilateral rectus abdominis retracted laterally • Retro-rectus space created • Dissecting balloon inserted deep to posterior rectus sheath, advanced to pubic symphysis and inflated • Space is insufflated and additional trocars placed • The inferior epigastric vessels are identified that serve as a landmark. • Nerves that can be damaged Femoral branch of genitofemoral N, LFCN of thigh
  • 52.
    • TAPP approach •Infraumbilical incision given to access peritoneal cavity directly • Two 5-mm ports placed lateral to inferior epigastric vessels at level of umbilicus • Peritoneal flap created extending from median umbilical fold to ASIS • Rest steps as per TEP • Hernia reduction • Small hernias reduces itself • Large sac is divided with cautery, near internal inguinal ring leaving distal sac in situ, proximal peritoneal sac is closed with loop ligature/ clips. • Mesh deployment and fixation • 12 cm X 14 cm polypropylene mesh used • Covers direct, indirect, femoral
  • 54.
    Measurements for placingpolypropylene mesh • Dissect peritoneum 4 cm off cord structures • Fix mesh at least 2 cm above the hernia defect Structures in which the mesh is fixed Medially Cooper ligament Anteriorly Posterior of the rectus abdominis muscle and transversus abdominis Laterally Iliopubic tract Inferiorly is nerve  (within the triangle of doom) hence inferior tacker is not used
  • 56.
    Complications of inguinalhernia repair Recurrence • No significant differences amongst various techniques for repair • Risk of death is related to the comorbid conditions of the patient • Type of anesthesia doesn’t affect the recurrence rate of hernia • Recurrence rate of hernia 1.7-10%. Tension free repair have low hernia recurrence rate than tissue repair • Open and laparoscopic have similar rate of hernia recurrence • Danish Hernia data base Lichtenstein mesh repair hernia recurrence 25% • Shouldice repair has highest rate of recurrence • Approximately 50% of recurrence occurs within 3 years after primary repair • No difference in recurrence between TAPP and TEP repair.
  • 57.
  • 59.
    Boundary of femoralcanal • Anterior: Inguinal ligament • Posterior: Pectineal ligament • Lateral: Thin septum separating it from femoral vein. • Medial: Gimbernat’s ligament (lacunar ligament)
  • 60.
    Boundary of femoralhernia • Superiorly Iliopubic tract • Inferiorly Cooper ligament • Laterally  Femoral vein • Medially Junction of iliopubic tract and Cooper ligament (arcuate ligament)
  • 61.
    • 50% ofmen with femoral hernia will have associated direct inguinal hernia Repairing the femoral hernia • Can be cooper ligament repair/ preperitoneal approach/ laparoscopic approach. • Dissection and repair of hernial sac • Obliteration of defect in femoral canal • 2 ways to approximate • Iliopubic tract and Cooper ligament approximation • Prosthetic mesh placement • Mesh is not used in cases with strangulation • All femoral hernias should be repaired. • Recurrence • 2% after primary repair • 10% after re-repair • 3 types of repair is done in femoral hernia • Mc Evedy repair (High-inguinal) • Lothessian repair (Inguinal) • Lockwood repair (Low-inguinal) • 3 types of femoral hernia • Narath hernia lies beneath femoral vessels • Languier’s hernia Arises from gap in lacunar ligament (usually strangulated) • Cloquet hernia underneath the fascia of pectineus muscle
  • 62.
    Lockwood repair • Lowor infra-inguinal approach • Incision given directly over swelling • Sac is carefully dissected out • Sac ligated at neck, excised and hernia is repaired • Inguinal ligament sutured to cooper’s ligament – obliterates femoral ring • Indicated for uncomplicated hernia
  • 63.
    Lotheissein • Trans inguinalapproach • Incision 2cm above inguinal ligament; inguinal canal is opened • Hernial sac visualized • Excision of sac • Preferred when there is strangulated femoral hernia
  • 64.
    Mc Evedy • Highinguinal approach • Skin incision given 3 cm above pubic tubercle running laterally • Preferred in emergency setting when strangulation is suspected allowing better access to and visualization of bowel for possible resection • [Video demonstration of Mc Evedy incision and operation]
  • 65.
    Midline Abdominal Extraperitoneal FemoralHernioplasty (Henry Procedure) • Procedure of choice now for femoral hernia • Doesn’t damage the transversalis fascial floor
  • 66.
    Some caveats ofhernia • Recurrent hernias require placement of mesh for successful repair • Recurrent hernia after anterior repair require either laparoscopic repair/ posterior mesh placement • For bilateral inguinal hernia Giant prosthetic repair (Stoppa repair) or laparoscopic repair for simultaneous repair of both hernias
  • 67.
  • 68.
    Complications of herniarepair • Increased scarring and disturbed anatomy with hernia recurrence can result in an inability to identify important structures at operation. Hence different approach for recurrent hernias is recommended. • 10% overall complication of hernia • A. Surgical site infection • 1-2% of open repair • No recommendation for use of antimicrobials prior surgery • Patients with ASA 3 status cefazolin 2 to 3 g IV 30-60 minutes before the incision • In allergic patients Clindamycin 900 mg IV. • Superficial SSI open the incision, local wound care, secondary intention healing • Deep SSI Removal of the mesh • Treat any skin condition prior inguinal repair (if exists)
  • 69.
    B. Nerve injuriesand Chronic pain syndromes • Most commonly affected nerves in open repair ilioinguinal N, genital branch of GF N, iliohypogastric N. • Most commonly affected nerves in lap repair LFC nerve, GF nerve. • Neuralgias that occur may be: • Transient: Self-limited, sensory involvement • Persistent: pain and hyperesthesia, exacerbated by hyperextension of the hip and relieved by flexion of the thigh. • Chronic postherniorrhaphy pain: Pain persisting more than 3 months after operation • Strategies of routine nerve division have not been associated with reduction in chronic groin pain. • Division of ilioinguinal N is associated with significantly more sensory disturbances. • Management: • Identify and preserve all 3 N • Avoid direct fixation to Pubic tubercle • Minimal disruption of cremasteric muscle • Use of interrupted suture fixation superiomedially
  • 70.
    • Management ofresidual neuralgia • NSAIDS • Analgesics • Local anesthetics • Surgical approach to groin pain • Local intervention Mesh excision, Tack excision, Mesh debulking • Nerve-related intervention Neurectomy
  • 71.
    c. Ischemic orchitisand testicular atrophy • Occurs usually from thrombosis of small veins of pampiniform plexus within spermatic cord • Results in venous congestion Testicular swelling 2-5 days after surgery testicular atrophy • Caused by unnecessary dissection within spermatic cord • Especially while dissection of distal portion of large hernial sac • Hence for large hernias, posterior approach is preferred • Ischemic orchitis may lead to testicular atrophy • Incidence of ischemic orchitis increased by factor of 3-4 with each subsequent hernia repair. • Hence ischemic orchitis occurs while doing recurrent hernia repair • Management NSAIDS and anti- inflammatory
  • 72.
    d. Injury tovas deferens and viscera • Unusual • Usually in management of sliding hernia when there is failure to recognize presence of intraabdominal viscera in hernia sac e. Inguinal hernia recurrence • Caused by technical factors like excessive tension during hernia repair missed hernias failure to include an adequate musculoaponeurotic margin improper mesh size improper mesh placement failure to close patulous hernial ring intra abdominal pressure chronic cough deep infections poor collagen formation in wound Direct hernias recur more Femoral hernias may be present in cases with Inguinal hernia recurrence. Must be investigated.
  • 73.
    Management of recurrentinguinal hernias • Use prosthetic mesh • Choose different OT approach • Avoid dissection through scar tissue • Recurrences can be best managed by placing second prosthesis through different approach • Rate of recurrence is similar in both laparoscopic and open approach • Re-recurrence rates • 4-5% in first 24 months • 7.5% at 5 years
  • 74.
  • 75.
    Definition and incidence •A ventral hernia is protrusion through the anterior abdominal wall • May be spontaneous or acquired • Acquired hernias Incisional hernias • Diastasis recti stretch in Linea alba resulting in bulge at the medial margin of rectus muscle • Unless significantly symptomatic Don’t repair • Incisional hernia 15% • Umbilical hernia and epigastric hernia 10% • Incisional hernias are twice common in ladies • Causes • Obesity • Old age • Male • Sleep apnea • Emphysema • Prostatism • Wound infection
  • 76.
    • Incidence ofventral hernia and surgery incision types • Midline 10.5% • Transverse 7.5% • Paramedian 2.5% • Ventral hernias are to be repaired when discovered. • Classification of ventral hernia • Umbilical hernia • Epigastric hernia • Incisional hernia
  • 77.
  • 78.
    • Umbilical herniasin infants are congenital. • Most spontaneously close by 2 years • Persistent hernias after 5 years of age require surgery • Umbilical hernias in adults are acquired • More in women • Indications for repair • Large hernia • Incarceration • Uncontrollable ascites • Thinning of overlying skin • Mayo’s repair  vest over pants • Involves 2-layered imbrication of superior and inferior fascial edges • Mayo’s repair has recurrence of 30% Not done nowadays Defect size < 3cm Primary repair >3 cm Mesh repair
  • 79.
  • 80.
  • 81.
    • 3-5% ofhernias • 2-3 times more common in men • Usually in location between xiphoid process and umbilicus (5 to 6 cm within) • Feature is to produce pain out of proportion • Pain is caused by incarceration of preperitoneal fat • Repair involves: • Excision of preperitoneal tissue • Simple closure of fascial defect • Epigastric hernias are repaired anteriorly
  • 82.
  • 83.
    • Most challengingand difficult • Occurs as a result of excessive tension and inadequate healing of previous incisions • Hernias enlarge over time, cause pain, bowel obstruction, incarceration and strangulation • Risk factors • Obesity • Advanced age • Malnutrition • Ascites • Pregnancy • COPD • DM • Immunosuppressants • SSI • Loss of domain hernias Abdominal contents can no longer stay in the cavity and protrude • With loss of domain hernias, natural rigidity of abdominal wall becomes compromised and abdominal musculature is retracted. • Results of loss of domain • Respiratory dysfunction • Bowel edema • Stasis of splanchnic circulation • Urinary retention • Constipation
  • 85.
    • Width ofthe hernia and presence of contamination are the 2 variables associated with wound morbidity and hernia recurrence. • Hernia classification using width and wound class alone
  • 86.
    Management of ventralhernia • Primary done is done when • Hernia is <3 cm diameter • Viable surrounding tissue • Hernia created by technical error in previous operation • Prosthesis (E.g. Mesh) • Hernia > 3 cm in diameter • Prosthetic materials used for hernia repair • Permanent synthetic materials • Characteristics of an ideal mesh • Chemically inert • Resistant to mechanical stress • Sterilizable • Compliant • Non carcinogenic • Non inflammatory • Hypoallergenic • [@ CRS-CNN-H]
  • 87.
    • 1.Permanent syntheticmesh • Consider position of the mesh • Presence of risk of infection • Mesh can be classified on the basis of • Weight of material • Pore size (Macro/ microporous) • Water angle (hydrophobic/ hydrophilic) • Whether adhesive barrier is present/not • Choice of mesh • Extraperitoneal microporous, unprotected mesh, prolene/polyester mesh • Intraperitoneal Various options are available • [See next slide] Mesh Weight Lightweight < 40g/m2 Medium weight 40-60 g/m2 Intermediate weight 60-75 g/m2 Heavy weight >75 g/m2 Lightweight vs heavyweight Lightweight is favored When recurrence is the issue Heavyweight is favored Bacterial contamination Large pore synthetic mesh is used [ animal studies] Complex ventral hernias Polyester mesh (microporous mesh)
  • 89.
    • 2. Biologicalmesh • Nonsynthetic, natural tissue mesh • Classified as • Source Human/ Porcine/ Bovine • Postharvest processing Cross-linked/non-cross-linked • Sterilization techniques Gamma radiation, Ethylene oxide gas • Contain acellular collagen make it suitable to be used in infected/ contaminated cases. • Function best when used as fascial reinforcement rather than bridge or interposition repair • 3. Absorbable synthetic mesh • Polyglactin used to construct absorbable synthetic mesh • Mesh can be placed in any plane but typically with soft tissue covering mesh anteriorly • Can be used in contaminated complex ventral hernia repair
  • 90.
  • 91.
    • Sublay maybe further of • Rectorectus (Rectomuscular) • Preperitoneal • Intraperitoneal • Highly desirable to place mesh beneath the fascia. • 1. Intraperitoneal mesh placement • Composite mesh • 4 cm fascial- mesh overlap • Interrupted mattress suture • Mesh placement may be • Onlay • Interposition (Inlay) • Sublay
  • 92.
    • 2. Myofascialreleases • Fascial layer is separated from the muscular layer in the abdominal wall • Basic principle • Abdominal wall and rectus muscle are bounded by several different myofascial compartment • By releasing one or more fascial bundles, advancement of the rectus muscle to the midline is possible • Each of these procedures creates a local advancement flap of the rectus muscle • 3. Posterior rectus sheath incision with retromuscular mesh placement [Stoppa repair] • A prosthetic mesh is placed in extraperitoneal position in preperitoneal space or retro rectus position • Mesh placed on top of posterior rectus sheath or peritoneum • Mesh extends 5-6 cm beyond superior and inferior borders of the defect
  • 93.
    4. Component separation Posteriorcomponent separation • Also called as transversus abdominis release • Prerequisites • Tobacco free 1 month prior and 2 months after surgery • Albumin > 3.5 g/dl • HbA1C <7.0 • Pre-habilitation, 30 mins of walk per day • BMI < 35 Steps of posterior component separation 1. Incision and adhesiolysis 2. Packing of content 3. Incision of posterior rectus sheath 4. Retrorectus dissection 5. Transversus abdominis release 6. Retromuscular dissection 7. Posterior rectus closure (Zip sign) 8. Patch with Vicryl mesh 9. TAP block 10. Mesh deployment 11. Closure of midline 12. Skin closure
  • 100.
    Anterior component separation •Involves separating the lateral muscle layer of the abdominal wall to allow their advancement • Anterior component separation done on both sides allow a mobilization of 20 cm • Too lateral advancement can lead to lateral bulging or lateral herniation Steps of anterior component separation • Raise large subcutaneous flap above EOM fascia • Flaps retracted laterally past linea semilunaris • Preserve perforators to SC flaps • Relaxing incision is given 2 cm lateral to Linea semilunaris on lateral EO aponeurosis superiorly from subcostal margin to pubis • Blunt separation of EOM from IOM
  • 102.
    Some unusual hernias a.Spigelian hernias • Hernia between rectus muscle and semilunar line • Caused by absence of posterior rectus fascia. • Hernias are often interparietal with hernia sac dissecting posterior to the EO aponeurosis • Small hernias (1-2 cm) • 4th to 7th decade • USG/CT based diagnosis • Repaired by primary/ mesh repair • Open/ Laparoscopic technique can be used b. Obturator hernia • Patients present with evidence of compression of the obturator nerve which causes pain over anteromedial aspect of the thigh (Howship-Romberg sign) • Pain relieved by thigh flexion • Bowel obstruction is present • CT based diagnosis • Repaired by: Posterior approach • Hernia reduced • Preperitoneal fat pad within canal reduced • Obturator foramen is repaired with prosthetic mesh.
  • 104.
    c. Lumbar Hernia •Occur in region of posterior abdominal wall. MC Male, left side • May occur through superior and inferior lumbar triangle • Superior lumbar triangle (Grynfelt triangle) herniation is more common • Cause: Weakness in lumbodorsal fascia • Lumbar hernia doesn’t strangulate • Repaired by mesh placement which is sutured beyond the margins of the hernia (Dowd’s operation) • Grynfelt triangle: Bounded by (@ 12 PI) • 12th rib • Paraspinal muscles • Internal oblique muscle • Petit triangle: Bounded by (@ LIE) • Latissimus dorsi • Iliac crest • EOM
  • 106.
    Loss of domainhernias • Massive hernias in which the herniated contents cannot be replaced into the peritoneal cavity • Types: • With pre-operative contamination • Without pre-operative contamination • Also classified as • Small hernial defect [ t/t PPP] • Massive hernial sac [t/t PTFE dual mesh] Management • Careful pre-op evaluation • Follow pre-requisites for component separation • For large hernias staged approach using PTFE dual mesh and lateral retraction of abdominal wall musculature is done • Initial stage reduction of hernia, placement of large PTFE dual mesh, suture mesh to fascial edge • Subsequent stage serial excision of the mesh until fascia can be approximated • Finally, mesh completely excised and fascia reapproximated by component separation and biologic underlay patch
  • 107.
  • 108.
    Parastomal hernia • Incidenceof stomal hernia is more for colostomies and is approximately 50% • Routine repair of parastomal hernias is not recommended • Indications • Bowel obstruction • Problems with pouch fit • Cosmetic issues • Repair approaches • Primary fascial repair • Stoma relocation • Prosthetic repair 1. Primary fascial repair hernia reduction and fascial reapproximation through peristomal incision. High recurrence rate 2. Prosthetic repair (using mesh) • Has excellent long term results with lower hernia recurrence. • Complications • Erosion • Obstruction • Approach • Onlay • Intraabdominal / Intraperitoneal • Retrorectus
  • 109.
    Techniques of parastomalhernia repair • Sugar baker procedure (Mesh flap) • Mesh placed intraperitoneally • Stoma placed as flat sheet/ keyhole fashioned around the stoma • Lateralize the stoma as it exits the abdomen • Rectomuscular repair (keyhole mesh repair) • Laparotomy performed • Stoma taken down • Resited to contralateral abdomen • Posterior component separation done • Large mesh placed in retromuscular area to cover old stoma site, new midline incision and reinforce new stoma site • Stoma brought out through keyhole incision in mesh and matured.
  • 111.
    Miscellaneous information • Seromaformed after mesh placement should be extracted only after 6-8 weeks. Drain placement can be done to reduce seroma formation. • Mesh infection: • 2 types of presentation • Acute with sepsis • Chronic indolent infection • Acute cases • Admission • IV antibiotics • Early debridement and mesh removal • Chronic cases • Per cutaneous drainage of fluid • Antibiotic suppression • CT scan to assess resolution of fluid  if low volume of fluid drain is removed
  • 112.

Editor's Notes

  • #7 What is Lytl’s repair?
  • #107 BTA Botulism toxin administration