Ventral HerniasFinal

7/28/2019 Ventral HerniasFinal

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HERNIASJessica Isom

MS3


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Definition

Ventral hernias result from defects in the abdominal wall.

Characterized by etiology and location.

Occur due to prior surgery (incisional) or spontaneously

(umbilical, Spigelian, or lumbar hernias)


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Epidemiology

In the United States, approximately 1,000,000 abdominal

wall herniorrhaphies are performed each year:

750,000 are for inguinal hernias,

166,000 for umbilical hernias,

97,000 for incisional hernias,

25,000 for femoral hernias, and

76,000 for miscellaneous hernias


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Types of Ventral Hernias


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Abdominal Wall Anatomy

Innervation: ventral rami 7-12th

Campers and Scarpa fascia

External Oblique

Internal Oblique

Transversus Abdominis

Endoabdominal fascia is thedeep fascia covering the internal

surface of the transversusabdominis


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External Oblique

Posterior portion inserts crest of ilium, anterior portionpubis of which fibers fold back on themselves to forminguinal ligament laterally attached toASIS. In mostpersons, the medial insertion of the inguinal ligament is

dual The lacunar ligament blends laterally with the Cooper

ligament (or, to be anatomically correct, the pectinealligament).

The more medial fibers of the aponeurosis of the externaloblique muscle divide into a medial crus and a lateral crusto form the external or superficial inguinal ring, throughwhich the spermatic cord (in females, the round ligament)and branches of the ilioinguinal and genitofemoral nervespass.


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Internal Oblique

The fibers of the internal oblique muscle fan out following

the shape of the iliac crest

The lower fibers orient themselves inferomedially towardthe pubis to run parallel to the external oblique

aponeurotic fibers.

These fibers arch over the round ligament or thespermatic cord, forming the superficial part of the internal

(deep) inguinal ring.


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Transversus Abdominis

This muscle arises from the inguinal ligament, the inner side ofthe iliac crest, the endoabdominal fascia, and the lower sixcostal cartilages and ribs

Infrequently, these fibers are joined by a portion of the internal

oblique aponeurosis; only when this occurs is a true conjoinedtendon formed.

Aponeurotic fibers of the transversus abdominis also form thestructure known as the aponeurotic arch

The transverse aponeurotic arch is also important because theterm is used by many authors to describe the medial structurethat is sewn to the inguinal ligament in many of the olderinguinal hernia repairs.


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Stoppa ProcedureBetween the transversalis fascia and the

peritoneum is the preperitoneal space. In the

midline behind the pubis, this space is known

as the space of Retzius; laterally, it is referred

to as the space of Bogros.

The preperitoneal spaceseveral herniarepairs are performed in this area.

The technique is suited for recurrent hernias

in which scarring and obliterated anatomy

increase the risk of cord injury and

recurrence. Other problems such as large

hernias and femoral hernias are corrected

with this approach.

Shown is a laparoscopic

view of the anatomy of

the left groin with the

peritoneum intact in a

patient without a hernia.

IEV = inferior epigastricvessels; IR = internal ring;

MUL = medial umbilical

ligament; TV = testicular

vessels; VD = vas

deferens.


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Incisional Hernia

Most common type of ventral hernia,

Best definition of incisional hernia is any abdominal wall

gap, with or without a bulge that is perceptible on clinicalexamination or diagnostic imaging within 1 year after the

index operation.

An analysis of 11 publications dealing with ventral herniaincidence after various types of incisions concluded that

the risk was 10.5% for midline incisions, 7.5% for

transverse incisions, and 2.5% for paramedian incision


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Incisional Hernia cont.

A RTC comparing midline versus transverse incisions did

not find a difference in analgesia use, pulmonary

complications, or hernia recurrence after 1 year but did

find increased wound infections in the transverse incision

group.

Most detected w-in 1 year of surgery; the MCC is

separation of aponeurotic edges in the early postoperative

period.

The male-to-female incidence ratio is 1:1, even though

early evisceration is more common in males.


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Parastomal Hernia

Most frequent complication following the construction of a

colostomy or an ileostomy

PE as an incisional hernia which develops in the region ofa colostomy or an ileostomy with the formation of a

peristomal vault when the loops are passed through the

aponeurotic orifice, which is clearly visible, as a result of

parietal strain or when the patient is in a standing position,

as a protrusion of the abdominal wall around the stoma

~1/3 operated on with high recurrence rate; abdominal

perimeter and age independently linked to greater risk


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Parastomal Hernias cont

A literature review found that PSH occurs in 1.8 to 28.3 percent of patients

with end ileostomies, 0 to 6.2 percent with loop ileostomies, 4.0 to 48.1

percent with end colostomies, and 0 to 30.8 percent with loop colostomies

The techniques for repair of PSH:

1) Relocation of the stoma

2) Direct repair of the fascia defect

3) Repair using a prosthetic mesh


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Parastomal Hernias cont

The high local failure rate of direct fascial repair for incisional, inguinal, andparastomal hernias and the evidence for defects in collagen metabolism ledto the development of local repairs with prosthetic mesh, which is the mostcommon method of PSH repair

Laparoscopic mesh repair decreased patient morbidity

improved outcomes with laparoscopic tension-free mesh repair of ventraland incisional hernias have led surgeons to apply these techniques to therepair of PSH.

Sugarbaker --widely used in laparoscopic repairs

avoids the need for making apertures in the mesh, which makelaparoscopic placement more difficult

Short-term results are promising (recurrence rate less than 2 percent

longer term results (more than 24 months) are not available


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Groin Hernias

Direct

Indirect

Femoral


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Epidemiology 3rd leading cause of ambulatory care visits for GI complaints in 2004; no change since 1975

Prevalence 5-10% in the United States.

Inguinal hernia>>femoral hernia

Femoral hernias (incarceration, strangulation)>> inguinal hernias.

Men>>women, whites>>non-whites

Men are eight times more likely to develop a hernia and 20 times more likely to need a herniarepair compared with women

The lifetime risk --25 percent in men; but less than 5 percent in women.

Women manifest groin hernias at a later age.

In one review, the median age at presentation was 60 to 79 years of age for women comparedwith 50 to 69 years of age for men

The peak age range at presentation for indirect hernia in women is 40 to 60 years ofage


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Inguinal Anatomy

Innervation

Vasculature


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Inguinal Anatomy cont. Spermat ic Cord Structures

The testicular artery and vein travel directly over and slightly lateral to theexternal iliac artery, and enter the internal spermatic ring posteriorly.

The vas deferens is best identified where it joins the spermatic vessels

Inferior Ep igastr ic Vessels

The inferior epigastric artery and vein lie on the medial aspect of theinternal inguinal ring

They are best identified by locating the internal inguinal ring at thejunction of the vas deferens and the testicular artery and vein. At thislocation, the vessels exit the medial margin of the internal ring.

Corona mortis is a vascular communication between the obturator arteryand the inferior epigastric artery found in 20% of patients


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Lower Abdominal Innervation

Geni tofemoral Nerve

The genitofemoral nerve pierces the psoas descends under theperitoneum on the psoas major, and divides into a medial genital and alateral femoral branch. The femoral branch descends lateral to the external iliac artery and spermatic cord,

into the femoral sheath to supply the skin over the femoral triangle.

The genital branch crosses the lower end of the external iliac artery and enters theinguinal canal through the internal inguinal ring with the testicular vessels. Thisbranch supplies the coverings of the spermatic cord down to the skin of the scrotum.

Il io ingu inal and Il iohyp ogastr ic Nerves

The ilioinguinal nerve--a small cutaneous area near the external genitals

The iliohypogastric nerve--the skin above the pubis.

Lateral Cutaneous Nerve of the Thigh

Descends deep to the peritoneum on the iliac muscle and comes to lie ina superficial position only 3 cm below the anterosuperior iliac spine. Itinnervates the front and lateral aspects of the thigh.


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Shown is the left inguinal region with the peritoneum removed, as seen

during laparoscopic inguinal hernia repair. The triangle of doom

contains the external iliac vessels. The triangle of pain is an area that

must be paid attention to during repair as multiple sensory nerves run in

this area and may cause significant postoperative neuralgia if injured.

Triangle of Doom & Pain


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Franz K. Hesselbach

German surgeon and anatomist (17591816), described a trianglethat is the common site of direct hernias.

The triangle is defined inferiorly by the inguinal ligament, superiorly bythe inferior epigastric vessels, and medially by the rectus fascia.

The transversalis fascia forms the floor of the triangle.

The original description used Coopers ligament as the inferior limit,but because of the common use of the anterior approach to hernias,the more apparent inguinal ligament was substituted as the inferior

limit of the triangle.

With the increasing use of Stoppa (preperitoneal) approaches tohernia repair, Coopers ligament is again much more apparent anduseful as an anatomic touchstone.


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Sir Astley Paston Cooper

English surgeon and anatomist (17681841) described a

ligament bearing his name.

The anatomic name of Coopers ligament is iliopectineal

ligament. The Coopers ligament repair or McVay repair

was popularized by Chester McVay (19111987).

With Barry Aston, professor of anatomy at Northwestern

University, McVay provided the modern description of the

groin anatomy.


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Antonio de Gimbernat

Spanish surgeon and anatomist (17341816), had his

interesting name attached to the lacunar ligament, which

marks the medial margin of a groin area opening.

.the femoral canal, which is defined medially by the

lacunar ligament, anteriorly by the inguinal ligament,

posteriorly by the pectineal fascia, and laterally by the

femoral vein.

A femoral hernia protrudes into

the femoral canal.


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Indications for Surgery

The general indications for inguinal hernia repair are the sameas for open and laparoscopic approaches, with the alternativeto surgical management being watchful waiting.

Some suggest surgeons are taught, first, that all hernias, even

asymptomatic ones, should be repaired at diagnosis to preventpotential strangulation or bowel obstruction and, second, thatherniorrhaphy becomes more difficult the longer the repair isdelayed.

Many surgeons consider the presence of an inguinal hernia tobe reason enough to operate; however, recent studies haveshown that the presence of a reducible, asymptomatic inguinalhernia in males is not an indication to operate as theincarceration rate is less than 1%.


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Recent Studies

Two trials were conducted to study the effects of watchfulwaiting for asymptomatic hernias and found that after long-termfollow-up, there was no significant difference in hernia-relatedsymptomatology.

Another long-term follow-up study determined that mostpatients with an asymptomatic groin hernia eventually developsymptoms and should be offered surgical repair if they aremedically fit.

One RTC, however, found: ITT outcomes similar at 2 years in both groups

23% crossed from WW to surgical repair

17% crossed from SR to WW

Self reported pain in WW improved after repair

Only one WW (0.3%) had incarceration w-in 2yrs, another

incarceration with SBO at 4yrs


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Surgical Techniques: Open vs Lap

National Institute for Health and Clinical Excellence

(NICE): a set of guidelines for the use of laparoscopic

inguinal hernia repair.

In choosing between open and laparoscopic surgery, the

following are considered: The suitability of the individual for general anesthesia

The nature of the presenting hernia

The suitability of the particular hernia for a laparoscopic or open repair

The experience and comfort level of the surgeon in the available technique options
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Laparoscopic vs Open Surgery

A retrospective chart review at the Carolinas Medical Center wasperformed on all patients who underwent laparoscopic ventral

hernia repair (LVHR) from July 1998 through December 2003.

LVHR was successfully completed in 270 of the 277 patients, or

98%, in whom it was attempted.

Half of the patients (138/277) had at least one previous failed

repair.

Thirty-four complications occurred in 31 patients (11%). Only two

mesh infections occurred (0.7%).

At a mean follow-up period of 21 months, the rate of herniarecurrence was 4.7%.

As experience grows and length of follow-up expands, LVHR may

become the preferred approach for ventral hernia in difficult

patients, especially obese patients and patients who have failed

prior open repairs.


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TEP AND TAPP

The most commonly performed laparoscopic repair

procedures are transabdominal preperitoneal (TAPP)

repair and totally extraperitoneal (TEP) repair.

During TAPP repair, surgeons enter the peritoneal cavity

to place a mesh through an incision over the hernia site.

With TEP surgery, surgeons do not enter the peritoneal

cavity but use a mesh to cover the hernia from outside the

peritoneum.


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Bassini repair

The Bassini repair sutures together the conjoined tendon

and the shelving edge of the inguinal ligament up to the

internal ring.

This classic procedure, introduced in 1887, the Italian

Society of Surgery in Genoa, revolutionized hernia repair.Until recently, it has been the standard of repair.

After graduation from medical school and while fighting for

Italian independence, Eduardo Bassini (18441924) was

bayoneted in the groin and, as a prisoner, washospitalized for months with a fecal fistula.


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Bassini

Over a follow-up

period of 50 years,

the recurrence rate

of adult indirect

hernias is 5% to

10%;

of direct hernias,

15% to 30%.


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McVay

Femoral and direct hernias.


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Shouldice repair

The Shouldice repair, popularized at the Shouldice Clinicnear Toronto, imbricates or overlays the transversalisfascia and conjoined tendon with four continuous lines,using two fine-wire sutures.

The suture tract runs from the pubic tubercle to a newinternal ring.

Care is taken with the inferior epigastric vessels.

The result is layered approximation of the conjoined

tendon to the inguinal ligament tract.


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Shouldice

The recurrence rate is 1%, the lowest reported rate fornonmesh repairs of inguinal hernias in adults.

Shouldice repair not appropriate for femoral hernia.


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Tension Free (Mesh) Repairs

The use of synthetic sheets of meshed material (mainlypolypropylene (Marlex) and polytetrafluoroethylene (Gore-

Tex)) was made popular by Lichtenstein around 1976. He

began using mesh in all primary hernia repairs mainly as

prophylaxis against recurrent direct herniation followingrepair for indirect herniation. Because of their space filling

properties, these materials not only provide strength to

the repair, but also release tissue tension on anatomic

structures.


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Mesh

Available as patches, plugs, or customized patterns, these

materials do not alter the anatomic features of the repair

and do not require the use of tension on adjacent

structures. An onlay patch is placed on the anterior

surface of the posterior wall of the inguinal canal from thepubic tubercle to above the internal ring. A slit made in the

mesh permits egress of the spermatic cord and the tails of

the mesh are overlapped. Some surgeons also place a

mesh plug (similar to a badminton shuttlecock) into theinternal ring as reinforcement. Over time the muscles and

tendons send out fibrous tissue which grows around and

through the mesh.


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Marlex Mesh

Not appropriate

for femoral

hernias


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Postoperative Complications

Chronic postoperative groin pain is one of the majorcomplications facing patients undergoing inguinal herniarepairs. some degree as many as 53% of patients,

significant long-term pain 5 to 15% of patients,

Persistent pain and burning sensations in the inguinal region, theupper medial thigh, or the spermatic cord and scrotal skin regionoccur when the genitofemoral nerve or the ilioinguinal nerve isstimulated, entrapped, or unintentionally injured.

When the lateral cutaneous nerve is involved, lateral or centralupper medial thigh numbness is experienced and often lasts severalmonths or longer
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Postoperative Complications

Postherniorrhaphy bleeding is usually the result of delayed bleedingfrom the

cremasteric artery,

the internal spermatic artery,

or branches of the inferior epigastric vessels.

This bleeding is usually self-limited but can produce an impressivewound or scrotal hematoma, which usually resolves over time.

Injuries to the deep circumflex artery or the external iliac vessels may

result in a large retroperitoneal hematoma

During laparoscopic repairs, the most common vascular injuriesoccurring are those involving the inferior epigastric vessels andthe spermatic vessels


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