CASE MANAGEMENT -CASE MANAGEMENT -PRESENTATION AND PRESENTATION AND

DISCUSSION ON DISCUSSION ON INCISIONAL HERNIAINCISIONAL HERNIA

BYBYHarvey A. Balucating, MDHarvey A. Balucating, MD

Department of SurgeryDepartment of SurgeryOspital ng Maynila Medical Ospital ng Maynila Medical

CenterCenter

R.C, 58/M FROM TONDO, R.C, 58/M FROM TONDO, MANILAMANILA

CHIEF COMPLAINTCHIEF COMPLAINT: BULGING : BULGING ABDOMINAL MASSABDOMINAL MASS

HISTORY OF PRESENT HISTORY OF PRESENT ILLNESS:ILLNESS:

2 yrs PTA 2 yrs PTA Px underwent ‘E’ Exploratory Laparotomy, Px underwent ‘E’ Exploratory Laparotomy, duodenorrhapy, omental patching sec duodenorrhapy, omental patching sec

to Perforated PUD.to Perforated PUD.

22 months PTA 22 months PTA noted bulging abdominal mass, noted bulging abdominal mass, about a size of a fist. Most about a size of a fist. Most

noticeable noticeable during straining or prolonged during straining or prolonged standing, reduced standing, reduced

sponataneously sponataneously on recumbent position. on recumbent position. (-) episode of vomiting(-) episode of vomiting (-) changes in BM(-) changes in BM Gradual increase in abdominal mass Gradual increase in abdominal mass

prompted Consult at OMMC and subsequent Admisssionprompted Consult at OMMC and subsequent Admisssion

PAST MEDICAL Hx:PAST MEDICAL Hx:– s/p ‘E’ Ex-Lap, duodenorrhaphy, omental patch for s/p ‘E’ Ex-Lap, duodenorrhaphy, omental patch for

Perforated Peptic Ulcer Disease – OMMC – July 2004Perforated Peptic Ulcer Disease – OMMC – July 2004– No HypertensionNo Hypertension– No DMNo DM

FAMILY Hx:FAMILY Hx:

No heredofamilial diseaseNo heredofamilial disease

PERSONAL/SOCIAL Hx:PERSONAL/SOCIAL Hx:

smoker, 20 pack-years, stopped last 2004smoker, 20 pack-years, stopped last 2004

occasional alcoholic beverage drinkeroccasional alcoholic beverage drinker

PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:BP= 120/80 CR=89 RR= 20 T=36.5BP= 120/80 CR=89 RR= 20 T=36.5

HEENT: pink palpebral cojunctiva,anicteric HEENT: pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPCsclera, No NAD, No CLAD, No TPC

C/L: SCE, no retractions, clear BSC/L: SCE, no retractions, clear BS

HEART: adynamic precordium, NRRR, no HEART: adynamic precordium, NRRR, no murmurmurmur

ABDOMEN: Flabby, ABDOMEN: Flabby, NABS, soft, non-NABS, soft, non-tendertender

(+) healed midline (+) healed midline incisionincision

(+) mass, soft, non-(+) mass, soft, non-tender, reducible, tender, reducible, around the umbilicus around the umbilicus with fascial defect with fascial defect approx 8 x 8 cms approx 8 x 8 cms around the umbilicusaround the umbilicus

(+) mass, soft, non-(+) mass, soft, non-tender, reducible, 6 tender, reducible, 6 cms above the cms above the umbilicus with fascial umbilicus with fascial defect approx 2x2 defect approx 2x2 cms.cms.

EXTREMITIES: full equal pulses, No EXTREMITIES: full equal pulses, No edemaedema

Salient Features:Salient Features:

58 y/o, M58 y/o, M

2-yr History of bulging abdominal mass, 2-yr History of bulging abdominal mass, reduciblereducible

Fascial defect approx 8 x 8 cms and 2 x Fascial defect approx 8 x 8 cms and 2 x 2 cms2 cms

History of previous operationHistory of previous operation

BULGING ABDOMINAL MASSBULGING ABDOMINAL MASS

Hernia Hernia Non-HerniaNon-Hernia

Incisional Epigastric Intra-peritoneal AbdominalIncisional Epigastric Intra-peritoneal Abdominalhernia herniahernia hernia wall wall

hollow solidhollow solid Skin SubQ Skin SubQ MuscleMuscle

viscus organviscus organ UmbilicalUmbilical herniahernia

Clinical DiagnosisClinical Diagnosis::

DiagnosisDiagnosis CertaintyCertainty TreatmentTreatment

Incisional Hernia Incisional Hernia without without obstruction or obstruction or gangrenegangrene

99%99% SurgicalSurgical

Incisional Hernia Incisional Hernia with obstruction with obstruction or gangreneor gangrene

1%1% SurgicalSurgical

Do I need a para-clinical Do I need a para-clinical diagnostic procedure?diagnostic procedure?

NONO

BASIS:BASIS:

Patient with history of on and off bulging Patient with history of on and off bulging mass on incision site, s/p ‘E’ Exploratory mass on incision site, s/p ‘E’ Exploratory Laparotomy will give us a diagnosis of Laparotomy will give us a diagnosis of Incisional Hernia with 99% certainty.Incisional Hernia with 99% certainty.

Pretreatment Diagnosis

DiagnosisDiagnosis CertaintyCertainty TreatmentTreatment

Incisional Hernia Incisional Hernia without obstruction without obstruction or gangreneor gangrene

99%99% SurgicalSurgical

Incisional Hernia with Incisional Hernia with obstruction or obstruction or gangrenegangrene

1%1% SurgicalSurgical

TREATMENTTREATMENT

PRETREATMENT DIAGNOSIS:PRETREATMENT DIAGNOSIS:

Incisional Hernia without obstruction or Incisional Hernia without obstruction or gangrene s/p…gangrene s/p…

TREATMENTTREATMENT

GOALS OF TREATMENT:GOALS OF TREATMENT:- reduce hernial content- reduce hernial content- repair the fascial defect- repair the fascial defect- prevent recurrence of incisional - prevent recurrence of incisional

hernia after the repairhernia after the repair

TREATMENT OPTIONSTREATMENT OPTIONSTREATMENTREATMEN

TTBENEFITBENEFIT RISKRISK COSTCOST AVAILAVAIL

Simple non-Simple non-prosthesis prosthesis repairrepair

Ease in Ease in repair, repair, shorter OR shorter OR timetime

25-55% 25-55% recurrencrecurrence ratee rate11

OR OR costcost

availableavailable

Incisional Incisional herniorrhaphherniorrhaphy with mesh y with mesh (Sublay (Sublay Prosthesis Prosthesis repair)repair)

Relatively Relatively lower lower recurrence recurrence raterate

1-20% 1-20% recurrencrecurrence ratee rate

ProsthesiProsthesis-related s-related infection infection (5%) (5%) 22

OR OR cost + cost + P6,00P6,0000

availableavailable

1. Korenkov et. al., Langenbeck’s Arch Surg, 20001. Korenkov et. al., Langenbeck’s Arch Surg, 2000

2. American College of Surgeons, 20042. American College of Surgeons, 2004

TREATMENT OF CHOICETREATMENT OF CHOICE

SUBLAY PROSTHESIS REPAIRSUBLAY PROSTHESIS REPAIR

PREOPERATIVE PREPARATIONPREOPERATIVE PREPARATION

Informed consentInformed consentPsychosocial supportPsychosocial supportOptimize patient’s healthOptimize patient’s healthScreen for any condition that will interfere Screen for any condition that will interfere with treatmentwith treatmentPrepare materialsPrepare materials

1. Prolene Mesh1. Prolene Mesh

OPERATIVE TECHNIQUEOPERATIVE TECHNIQUE

Patient supine under CLEAPatient supine under CLEA

Asepsis/AntisepsisAsepsis/Antisepsis

Sterile drapesSterile drapes

Excision of scarred incision skinExcision of scarred incision skin

Subfascial flap dissection separating Subfascial flap dissection separating rectus from peritoneum/hernial sacrectus from peritoneum/hernial sac

Hernial sac openedHernial sac opened

OPERATIVE TECHNIQUE cont..OPERATIVE TECHNIQUE cont..

Inspection of intraabdominal organs for gut Inspection of intraabdominal organs for gut adhesions and additional fascial defectsadhesions and additional fascial defectsSilk suture laid on peritoneum for mesh Silk suture laid on peritoneum for mesh anchoringanchoringInterrupted Silk 2-0 sutures approximating Interrupted Silk 2-0 sutures approximating small superior fascial defectsmall superior fascial defectExcess peritoneum trimmedExcess peritoneum trimmedClosure of peritoneum with chromic 3-0 Closure of peritoneum with chromic 3-0 simple continuoussimple continuous

OPERATIVE TECHNIQUE cont..OPERATIVE TECHNIQUE cont..

Mesh laid over the area of larger defectMesh laid over the area of larger defect

Anchoring sutures tiedAnchoring sutures tied

Closure of fascia with simple continuous suture, Closure of fascia with simple continuous suture, Vicryl-0Vicryl-0

HemostasisHemostasis

Running continuous with Vicryl 2-0 Running continuous with Vicryl 2-0 subcutaneoussubcutaneous

Subcuticular Vicryl 4-0Subcuticular Vicryl 4-0

Correct sponge and instrument countCorrect sponge and instrument count

Dry Sterile DressingDry Sterile Dressing

OPERATIVE TECHNIQUEOPERATIVE TECHNIQUE

OPERATIVE FINDINGSOPERATIVE FINDINGS

7 cms fascial defect from umbilicus down 7 cms fascial defect from umbilicus down and 1 cm aboveand 1 cm above

Small fascial defect approx 1x1 cms, 6 Small fascial defect approx 1x1 cms, 6 cms superior to the umbilicus, left of the cms superior to the umbilicus, left of the midlinemidline

No incarcerated bowel notedNo incarcerated bowel noted

OPERATION DONE: Incisional OPERATION DONE: Incisional Herniorrhaphy with subfascial Herniorrhaphy with subfascial

prosthesisprosthesis

POST-OP CAREPOST-OP CARESufficient analgesiaSufficient analgesiaNutritionNutritionWound careWound careMonitoring of complications and treat as Monitoring of complications and treat as indicatedindicatedAdvice on home care of woundAdvice on home care of woundAdvice on ff-up plansAdvice on ff-up plans

SHARING OF INFORMATIONSHARING OF INFORMATION

INCISIONAL HERNIAINCISIONAL HERNIA

occur as a complication of previous occur as a complication of previous surgery surgery Causes:Causes:

1. 1. poor surgical technique poor surgical technique 2. rough handling of tissues2. rough handling of tissues3. use of rapidly degraded 3. use of rapidly degraded

absorbable suture materials absorbable suture materials 4. closure of the abdomen 4. closure of the abdomen

under tension, under tension, 5. infection5. infection

6. 6. Male sexMale sex7. advanced age7. advanced age8. morbid obesity8. morbid obesity

9.abdominal disstention 9.abdominal disstention 10. cigarette smoking10. cigarette smoking 11. pulmonary disease11. pulmonary disease 12. hypoalbuminemia12. hypoalbuminemia

The incidence of incisional hernia was The incidence of incisional hernia was significantly lower when significantly lower when nonabsorbable sutures were used in a nonabsorbable sutures were used in a continuous closure; however, the continuous closure; however, the incidence of suture sinus formation incidence of suture sinus formation (9%) and that of wound pain were (9%) and that of wound pain were significantly highersignificantly higher (MEDLINE and (MEDLINE and Cochrane database)Cochrane database)

The best definition is any abdominal The best definition is any abdominal wall gap, with or without a bulge, that is wall gap, with or without a bulge, that is perceptible on clinical examination or perceptible on clinical examination or imaging by 1 year after the index imaging by 1 year after the index operation. operation.

Incidence: 3 – 20% (double if the index Incidence: 3 – 20% (double if the index operation is associated with infection)operation is associated with infection)

Risk:Risk: midline - 10.5% midline - 10.5% transverse - 7.5%, transverse - 7.5%, paramedian - 2.5% paramedian - 2.5%

Early evisceration is commonly seen Early evisceration is commonly seen among males.among males.Incarceration and strangulation occur Incarceration and strangulation occur with significant frequency, and with significant frequency, and recurrence rates after operative repair recurrence rates after operative repair approach 50%.approach 50%.

Classification of incisional Classification of incisional herniashernias

I. According to localization (modified I. According to localization (modified Chevrel) Chevrel)

–VerticalVertical1.1. Midline above or below umbilicus1.1. Midline above or below umbilicus1.2. Midline including umbilicus right or left1.2. Midline including umbilicus right or left1.3. Paramedian right or left1.3. Paramedian right or left

–TransversalTransversal2.1. Above or below umbilicus right or left2.1. Above or below umbilicus right or left2.2. Crossed midline or not2.2. Crossed midline or not

–ObliqueOblique3.1. Above or below umbilicus right or left3.1. Above or below umbilicus right or left

–CombinedCombined (midline + oblique; midline + (midline + oblique; midline + parastomal; etc)parastomal; etc)

II. II. According to sizeAccording to size–Small (<5 cm in width or length)Small (<5 cm in width or length)–Medium (5-10 cm in width or length)Medium (5-10 cm in width or length)–Large (>10 cm in width or length)Large (>10 cm in width or length)

III. According to recurrenceIII. According to recurrence–Primary incisional herniaPrimary incisional hernia–Recurrence of an incisional herniaRecurrence of an incisional hernia (1., (1.,

2., 3., etc. with type of hernioplasty: 2., 3., etc. with type of hernioplasty: adaptation, Mayo-duplication, prosthetic adaptation, Mayo-duplication, prosthetic implantation, autodermal etc.)implantation, autodermal etc.)

IV. According to the situation at the IV. According to the situation at the hernia gatehernia gate

– Reducible with or without obstructionReducible with or without obstruction– Irreducible with or without obstructionIrreducible with or without obstruction

According to symptomsAccording to symptoms– AsymptomaticAsymptomatic– SymptomaticSymptomatic

Operative TechniqueOperative Technique:I. Simple Non-Prosthesis RepairII. Posthesis Repair

a. Onlay Prosthetic Repairb. Prosthetic Bridging Repairc. Combined Fascial and

Mesh Closured. Sublay Prosthetic Repair

Simple Non-Prosthesis RepairSimple Non-Prosthesis Repair

recurrence rate ranges from 25% to recurrence rate ranges from 25% to 55%55%According to the experts' According to the experts' recommendation, the fascia-duplication recommendation, the fascia-duplication should only be used for small should only be used for small incisional hernias (3 cm or less) and if incisional hernias (3 cm or less) and if the reconstruction of the repair is the reconstruction of the repair is oriented horizontallyoriented horizontally (Korenkov et al, (Korenkov et al, 2000).2000).

monofile non-resorbable material - U-monofile non-resorbable material - U-suture by Mayo-duplication or running suture by Mayo-duplication or running suture with a suture:wound length ratio suture with a suture:wound length ratio of 4:1.of 4:1.

Prefascial (Onlay) Prosthetic Prefascial (Onlay) Prosthetic Implantation (Chevrel-technique)Implantation (Chevrel-technique)

The recurrence rates indicated in the The recurrence rates indicated in the literature vary between 2.5% and 13.3%literature vary between 2.5% and 13.3%

Authors using this technique estimate Authors using this technique estimate the amount of wound healing the amount of wound healing complications after this operation to complications after this operation to range between 4% and 26% and range between 4% and 26% and estimate the rate of prosthesis estimate the rate of prosthesis removals between 0% and 2.5%removals between 0% and 2.5%

The main disadvantage of the onlay The main disadvantage of the onlay technique is the direct contact of the technique is the direct contact of the prosthesis (partly or completely) with prosthesis (partly or completely) with the environment during the wound the environment during the wound revision, which can cause wound revision, which can cause wound healing complicationhealing complications. s.

"subprosthetic hernia""subprosthetic hernia"

Subfascial Prosthetic Repair (Sublay Subfascial Prosthetic Repair (Sublay Technique)Technique)

retromuscular approachretromuscular approach

placement of a large prosthesis in the placement of a large prosthesis in the space between the abdominal muscles space between the abdominal muscles and the peritoneum.and the peritoneum.

To date, no controlled study has been To date, no controlled study has been published that has tested the sublay published that has tested the sublay technique versus the onlay technique technique versus the onlay technique (Korenkov et al, 2000).(Korenkov et al, 2000).

Recurrence rate 1 – 20% Recurrence rate 1 – 20% (Korenkov et al, (Korenkov et al, 2000).2000).

Choice of ProsthesisChoice of Prosthesis

Type I. - Type I. - Totally macroporous prostheses Totally macroporous prostheses (pores larger than 75 µm)(pores larger than 75 µm)

Marlex Marlex Monofilament polypropyleneMonofilament polypropyleneProlene Prolene Double filament polypropyleneDouble filament polypropyleneAtrium Atrium Monofilament polypropyleneMonofilament polypropylene

Type II. - Type II. - Totally microporous prostheses Totally microporous prostheses (pores less than 10 µm)(pores less than 10 µm)

Gore-Tex Gore-Tex

Expanded PTFEExpanded PTFE

Type III - Type III - Mix-prostheses Mix-prostheses (macroporous with multifilamentous (macroporous with multifilamentous or microporous components)or microporous components)

Teflon Teflon PTFE meshPTFE meshMersilene Mersilene Braided Dacron meshBraided Dacron meshSurgipro Surgipro Braided polypropylene meshBraided polypropylene meshMicroMesh MicroMesh Perforated PTFE patchPerforated PTFE patch

Autodermal hernioplastyAutodermal hernioplasty

According to the literature, the According to the literature, the recurrence rates of the autodermal recurrence rates of the autodermal hernioplastic and the prosthetic hernioplastic and the prosthetic strengthening are comparablestrengthening are comparable

Laparoscopic Hernia RepairLaparoscopic Hernia Repair

Laparoscopic incisional hernia repair Laparoscopic incisional hernia repair may be considered for any ventral may be considered for any ventral hernia in which mesh will be used for hernia in which mesh will be used for the repair. the repair.

Contraindication: suspected Contraindication: suspected strangulated bowel or loss of domainstrangulated bowel or loss of domain

Poor results of Incisional Hernia Poor results of Incisional Hernia RepairRepair

1. preexisting comorbid conditions1. preexisting comorbid conditions

2. cancer-related debilitation2. cancer-related debilitation

3. morbid obesity3. morbid obesity

4. use of steroids4. use of steroids

5. chemotherapy5. chemotherapy

MCQMCQ

1. Contraindication for laparoscopic hernia 1. Contraindication for laparoscopic hernia repair.repair.

a. patients with suspected a. patients with suspected strangulated bowelstrangulated bowel

b. Swiss cheese herniab. Swiss cheese hernia

c. defects in close proximity to the c. defects in close proximity to the bony margins of the abdomen bony margins of the abdomen

d. dense adhesions d. dense adhesions

MCQMCQ

1. Contraindication for laparoscopic hernia 1. Contraindication for laparoscopic hernia repair.repair.

a. patients with suspected a. patients with suspected strangulated bowelstrangulated bowel

b. Swiss cheese herniab. Swiss cheese hernia

c. defects in close proximity to the c. defects in close proximity to the bony margins of the abdomen bony margins of the abdomen

d. dense adhesions d. dense adhesions

2.2. Incisional hernia wioth fascial gap of 10 x Incisional hernia wioth fascial gap of 10 x 6 cms is considered:6 cms is considered:

a. Smalla. Small

b. Mediumb. Medium

c. Largec. Large

d. Not enough data to classifyd. Not enough data to classify

2.2. Incisional hernia with fascial gap of 10 x Incisional hernia with fascial gap of 10 x 6 cms is considered:6 cms is considered:

a. Smalla. Small

b. Mediumb. Medium

c. Largec. Large

d. Not enough data to classifyd. Not enough data to classify

3. Predisposing Condition for the 3. Predisposing Condition for the development of incisional hernia except:development of incisional hernia except:

a. emphysemaa. emphysema

b. deep surgical site infectionb. deep surgical site infection

c. BMI of 24c. BMI of 24

d. Poor surgical techniqued. Poor surgical technique

3. Predisposing Condition for the 3. Predisposing Condition for the development of incisional hernia except:development of incisional hernia except:

a. emphysemaa. emphysema

b. deep surgical site infectionb. deep surgical site infection

c. BMI of 24c. BMI of 24

d. Poor surgical techniqued. Poor surgical technique

MCRMCR

1. True of Simple non-prosthetic repair of 1. True of Simple non-prosthetic repair of incisional hernia:incisional hernia:I. recurrence rate ranges from 25% to 55%.I. recurrence rate ranges from 25% to 55%.II. If there is a solitary defect 3 cm or less in II. If there is a solitary defect 3 cm or less in diameter, primary closure with absorbable diameter, primary closure with absorbable suture material is appropriatesuture material is appropriate.. III. Less time consuming and assoc with less III. Less time consuming and assoc with less complicationcomplicationIV. Because of the high recurrence rates, the IV. Because of the high recurrence rates, the simple fascia-duplication can no longer be simple fascia-duplication can no longer be regarded as the "gold standard" regarded as the "gold standard"

MCRMCR

4. True of Simple non-prosthetic repair of 4. True of Simple non-prosthetic repair of incisional hernia:incisional hernia:I. recurrence rate ranges from 25% to I. recurrence rate ranges from 25% to 55%.55%.II. If there is a solitary defect 3 cm or less in II. If there is a solitary defect 3 cm or less in diameter, primary closure with absorbable diameter, primary closure with absorbable suture material is appropriatesuture material is appropriate.. III. Less time consuming and assoc with less III. Less time consuming and assoc with less complicationcomplicationIV. Because of the high recurrence rates, the IV. Because of the high recurrence rates, the simple fascia-duplication can no longer be simple fascia-duplication can no longer be regarded as the "gold standard" regarded as the "gold standard"

5.5. Which of the ff prosthesis repair is/are Which of the ff prosthesis repair is/are true?true?

I. Prefascial prosthesis I. Prefascial prosthesis Implantation: subprosthesis herniaImplantation: subprosthesis hernia

II. Sublay Technique : large II. Sublay Technique : large prosthesis in the space between the prosthesis in the space between the abdominal muscles and the peritoneum.abdominal muscles and the peritoneum.

III. Combined Fascial and Mesh III. Combined Fascial and Mesh Closure: posterior fascia is closed Closure: posterior fascia is closed primarily, The anterior fascia is then primarily, The anterior fascia is then bridged with a prosthesisbridged with a prosthesis IV. Sublay Technique :not suited for IV. Sublay Technique :not suited for swiss-cheese hernia swiss-cheese hernia

5.5. Which of the ff prosthesis repair is/are true?Which of the ff prosthesis repair is/are true?I. Prefascial prosthesis Implantation: I. Prefascial prosthesis Implantation:

subprosthesis herniasubprosthesis herniaII. Sublay Technique : large II. Sublay Technique : large

prosthesis in the space between the prosthesis in the space between the abdominal muscles and the peritoneum.abdominal muscles and the peritoneum.

III. Combined Fascial and Mesh III. Combined Fascial and Mesh Closure: posterior fascia is closed Closure: posterior fascia is closed primarily, The anterior fascia is then primarily, The anterior fascia is then bridged with a prosthesisbridged with a prosthesis IV. Sublay Technique :not suited for swiss-IV. Sublay Technique :not suited for swiss-cheese hernia cheese hernia

THANK YOU!!!THANK YOU!!!

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ReferencesReferences