Transcript Incisional Hernias - St. Luke's

Incisional Hernias
Laura Withers, M.D.
St. Luke’s Roosevelt Grand Rounds
July 6, 2005
Anatomy of the Abdominal Wall
Superior to the
arcuate line
Inferior to the
arcuate line
Definition
A hernia is the
protrusion of an
organ through the
wall that normally
contains it. An
incisional hernia
occurs in the area
of an old surgical
scar. A ventral
hernia occurs in the
abdominal wall.
A Problem Encountered and
Produced by Surgeons:
• In the U.S. approximately 2 million
laparotomies are performed each year.
• The incidence of incisional hernias is
reportedly between 3%-20% . This results in
an estimated 60,000-400,000 ventral hernia
repairs per year.
• No repair, approach or material has become
a gold standard in the treatment of this
problem.
Clinical Presentation
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More than half of incisional hernias occur within the first two years
after primary operation.
A diffuse bulge directly under or adjacent to a previous incision.
Increased protrusion with valsalva or standing.
Cosmetic concerns or interference with work or activity are common
complaints.
Pain is unusual as a presenting symptom unless there are
incarcerated or strangulated structures.
The natural history of an incisional hernia is to enlarge and become
symptomatic.
Clinical Presentation and Workup
• Physical exam may not
be adequate in obese
patients, patients with
significant rectus
diastasis, patients with
laxity due to spinal
injury or patients who
have had multiple prior
abdominal surgeries. In
this case UGI,
ultrasound or CT may
be used.
Risk Factors
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Age Above 65 or 70
Male Gender
Malnutrition
Sepsis
Anemia
Uremia
Ascites / Liver Failure
Diabetes
Pulmonary Disease
Smoking
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Abdominal Distension
Obesity
Coughing / Retching
Urinary Retention
Post-op Ileus
Peritoneal Dialysis
Wound Infection
Corticosteroids
Chemotherapy
Immunosupression
Etiology
• Mechanical Factors – Intra-abdominal
pressure overwhelming a weakness in the
abdominal wall.
• Pathologic changes in collagen that
adversely affect wound healing.
•Type I collagen is dominant in a mature
scar
•Type III collagen dominates in the early
stages of wound healing
Factors such as smoking, malnutrition,
immunocompromise, wound infection and
underlying diseases are now understood to
interfere with normal collagen metabolism.
Prevention of Incisional Hernias
“The strength of a wound lies in the
musculoaponeurotic layer.”
Oblique or transverse incisions
are preferred in many cases
• because the pull of the
lateral abdominal wall
muscles is parallel to the
incision and there is less
distracting tension than that
on vertical incisions.
• because the tension on the
suture lies perpendicular to
the orientation of fibers in
the abdominal wall fascia.
Thus the suture is less likely
to pull through.
1.
Kocher or Right Subcostal
Incision: oblique abdominal
incision paralleling the
thoracic cage on the right of
the abdomen for
cholecystectomy.
5.
Pfannenstial Incision: A
transverse incision through the
external sheath of the rectus
muscles, about an inch above
the pubes. It follows natural
folds of the skin and curves
over mons pubis in such a way
that the pubic hairs cover the
scar.
8.
Rocky-Davis Incision: muscle
splitting transverse abdominal
incision employed in
appendectomy.
The Paramedian Incision
• The paramedian incision is a vertical
incision made parallel to and approximately
3 cm from the midline
– Rectus - retracted laterally
• The potential advantages of this incision
are:
– The rectus muscle is not divided
– The incisions in the anterior and posterior rectus
sheath are separated by muscle
– The incision is closed in layers –peritoneum and
posterior sheat the anterior sheath
Midline Incision:
• The most common and most
versatile approach.
• Closure
– 2 No. 1 continuous polypropolene sutures
that meet in the middle
– Bites incorporating all layers of the
abdominal wall except skin and fat - no
need to close the peritoneum
Suture Characteristics
• Nonabsorbable suture has
better tensile strength but can
persist and become a focus of
infection or a draining sinus
tract
• Monofilaments and inert
materials are less likely to be
associated with wound infection
• Braided materials knot more
securely than monofilament and
are less likely to stretch
• “Memory” describes a stitches
tendency to straighten over time
loosening and slipping. It is
overcome by tying square knots
and using an adequate number
of throws.
Suture Techniques
“ One centimeter back and one centimeter apart.”
• Bite – to prevent the suture from
pulling through it should be placed at
least 1 cm from the wound edge
• Spacing – to distribute the tension on
the tissues while also preventing
herniation between the sutures
stitches are placed about 1 cm apart
• Continuous vs. Interrupted Sutures –
continuous suturing may better
distribute the tension but if one bite
pulls loose it compromises the whole
closure
• Tension Sutures – Full thickness
sutures that help prevent dehisance
in cases of difficult abdominal
closure
Prevention of Trocar Site Hernias
The incidence of trocar site hernia has
been shown to be 0.65% to 2.80%
• midline, periumbilical port sites
greater than 5 cm and made with
bladed introducers often result in
incisional hernia if not closed.
Port Site Closure Technique
Indications for Incisional Hernia Repair
The presence of the hernia is indication
for repair in patients able to tolerate
surgery.
Strangulation and acute incarceration
are indications for urgent operation.
• Incarceration – Occurs in about (6-15%) of
incisional hernias
• Strangulation – Occur in about 2% of all
incisional hernias
Principles of Repair
• Tension Free Repair
• Incision - Chosen to Provide
Good Exposure of the
Defect
• Do Not Expose Bowel to
Reactive Mesh
• Clear Adequate Margins of
the Defect
• Skin Hygiene
• Antibiotic Prophylaxis
• Choice of Anethesia
• Avoid Counter-incisions
• When to Excise the Sac
Direct Open Repair
“Pants over Vest”
Direct Open Repair
• Other techniques for open, primary repair
include simple interrupted or continuous
suturing of the fascial edges or the use of
mattress, figure of eight or even internal
retention sutures.
• Direct repair is reserved for small defects
with the upper size limit cited as being
between 3 and 5 cm.
• Even in small hernias recurrence rates of up
to 50% have been reported with these
techniques.
Direct Open Repair For
Larger Defects
Open Onlay Mesh Repair
Open Inlay Mesh Repair
Rives-Stoppa Technique
Intraperitoneal Underlay Mesh
Repair
Pascal's principle—wide mesh overlap of defect
distributes pressure equally over larger surface area.
Laparoscopic Repair
Set Up and Trocar Sites
Laparoscopic Hernia Reduction
and Adhesiolysis
Hernia contents are gently reduced using broad
grasping instruments. External counter-pressure
aids the reduction.
The extent of the defect is assessed.
The margins of the defect may be marked on the skin. The
patch is measured and trimmed to fit. With the smooth side
down, 4-6 large fixation sutures are placed around the patch
and tied
Laparoscopic Mesh Insertion
Laparoscopic Mesh Fixation
A Few Mesh Materials
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Vicryl (polyglactin 910) woven mesh is prepared
from a synthetic absorbable copolymer of
glycolide and lactide, derived respectively from
glycolic and lactic acids. It is absorbable and
reactive.
Marlex, also known as Prolene - Polypropylene
non-absorbable, non reactive monofilament.
Polyester Fiber Mesh is nonabsorbable, knitted,
flexible and durable. It has a high degree of
porosity that allows tissue ingrowth.
Polytetrafluoroethylene (PTFE) and expanded
polytetrafluoroethylene (ePTFE) carbon and
fluorine based synthetic polymers that are
biologically inert and non-biodegradable in the
body. ePTFE is more commonly known by the
brand names Gore-Tex® and SoftForm.
Mesh Products by Bard
Bard Composix E/X mesh is
designed for laparoscopic ventral
hernia repair. Its low profile makes
it easy to manipulate, and its sealed
edge eliminates exposed mesh
along the perimeter.
The Bard Composix
Kugel patch has a
"memory recoil ring"
which helps the patch
to maintain its shape
during placement.
The Bard Ventralex patch is
designed for open repairs of defects
4 cm or less. The positioning pocket
and straps facilitate placement.
Mesh Products by Ethicon
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PROCEED* Surgical Mesh also has
two layers, a thin, bioresorbable
layer that separates its strong,
supportive mesh from underlying
viscera. It is a lightweight
construction to improve handeling
for laparoscopic procedures. It has
a special deploying tool.
ULTRAPRO* is
Partially
Absorbable
Mesh - the only
one in the US. It
culminates a
natural evolution
in mesh repair
toward lighter,
absorbable
material. So it
forms a flexible
scar
Mesh Products by Gore
• GORE DUALMESH is a soft,
ePTFE that has two
functionally distinct
surfaces: a closed structure
surface for reduced tissue
attachment and a
macroporous structure
surface for faster tissue
attachment
• GORE MYCROMESH® PLUS
Biomaterial has
antimicrobial technology.
This ePTFE biomaterial
contains silver carbonate
and chlorhexidine diacetate,
which inhibit bacterial
colonization on the patch for
up to 10 days postimplantation.
Complications of Incisional
Hernia Repair
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Enterotomy
Wound Infection
Mesh Infection
Persistent seroma
Prolonged Pain
Ileus
Bleeding/Hematoma
Recurrance
• Respiratory Distress
• Abdominal
Compartment
syndrome or IVC
compression
Algorithm For Enterotomy During
Laproscopic Incisional Hernia Repair
Enterotomy
YES
Spillage?
Repair and
proceed
No
No
Open to
repair and
complete
adhesolysis
Laparoscopic
repair possible?
YES
No Mesh Placement.
Staged repair to be
completed in several days
to weeks
Repair
laproscopically
and complete
adhesolysis
Wound and Mesh Infection
Is mesh was just a large foreign body in
an otherwise clean surgical wound?
• many wounds are inflamed but not
necessarily infected
• infected wounds need to be opened
– avoid exposing the underlying mesh if possible
• infections that involve polypropylene
meshes can be managed with surgical
drainage, excision of exposed, segments
and antibiotics
• Meshes (ePTFE) require removal in most
cases because they lack tissue ingrowth that
could combat the infection
Seroma
• The development of seroma is virtually
guaranteed after lap incisional hernia
repair and probably after repair with
mesh in general. They typically resolve
spontaneously without intervention
and are not considered a complication
unless they are clinically apparent
more than 8 weeks postoperatively.
Complications: Prolonged Pain
• In Rives-Stoppa or other open mesh
implantation it occurs in more than
10% of patients
• Transabdominal suture site pain after
laparoscopic ventral hernia repair
occurs in 1% to 3% of patients.
Contraindications to Lap
Incisional Hernia Repair
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Major loss of abdominal domain
Severe debilitation
Fewer than 5 years life expectancy
Respiratory distress
Pregnancy
Portal hypertension
Renal failure with presence of peritoneal
dialysis catheter
Possible Advantages of
Laparoscopic Repair
• Minimization of soft-tissue dissection
• To visualize much of the abdominal
wall leads to fewer missed hernias
• In obese patients
• Recurrent hernias- Avoids dissection
through the previous operative site.
Comparison studies of laparoscopic and open
ventral hernia repairs
# of patients
Morbidity
Lap
open
Mesh Infxn
Wound
Recur
infection
lap
open
lap
O L O L O
Name
Year
McGreevy
[48]
Raftopoulos
[49]
Wright [50]
2003
65
71
5
15
2
0
0
7
— —
2003
50
22
14
10
1
0
1
1
1
4
2002
90
90
15
31
1
1
1
8
1
5
Robbins
[51]
DeMaria
[36]
Chari [52]
Carbajo [35]
2001
18
31
—
—
1
4
1
0
— —
2000
21
18
13
13
1
2
1
4
1
2000
1999
14
30
14
30
2
20
2
6
0
0
1
3
— — — —
0 5 1 2
Ramshaw
[33]
Park [23]
1999
79
174
15
46
1
5
6
2
2
36
1998
56
49
10
18
2
1
0
2
6
17
Holzman
[53]
Percent
1997
21
16
5
5
0
1
1
0
2
2
23.2
30.2
2.0
3.
5
2.
6
5.
8
4.
0
16.
5
0
Comparing Laparoscopic to
Open: Prospective Studies
• Two prospective studies comparing laparoscopic
ventral hernia repair with open:
– Carbajo et al Surg Endosc. 1999
– DeMaria et al Surg Endoscopy 2000
They support the advantages purported by the previous
studies
• A design for a prospective, randomized multicenter
study organized by Dr. Itani from Harvard was
published in AJS in Dec. 2004.
– It is comparing laparoscopic repair with the Chevrel
primary repair with mesh onlay and hypothesizes that the
laparoscopic group will have fewer complications at 8
weeks post op
St Luke’s-Roosevelt
References
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Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg
1989;124:485-8.
Bucknall TE, BMJ 1982;284:931-3
Manninen MJ, Lavonius M, Perhoniemi VJ. Results of incisional hernia repair: a retrospective study
of 172 unselected hernioplasties. Eur J Surg 1991;157:29-31.
Bucknall TE, Burst Abdomen and incisional hernia: a prospective study of 1129 major
laparotomies. BJM 182;284:931-3. Pollack AV, Single-layer mass closure of major laparotomies by
continuous suturing. J R Soc MED 1979;72:889-93
Carlson MA, Ludwig KA, Condon RE. Ventral hernia and other complications of 1,000 midline
incisions. South Med J 1995;88:450-3.
Mastery of Surgery Dr. Penn and Dr. Baker
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill
Livingstone, Inc
Nonclosure of peritoneum: a reappraisal. Tulandi T - Am J Obstet Gynecol - 01-AUG-2003; 189(2):
609-12
Tonouchi H. Ohmori Y. Kobayashi M. Kusunoki M. Trocar site hernia. [Review] [63 refs] [Journal
Article. Review. Review of Reported Cases] Archives of Surgery. 139(11):1248-56, 2004 Nov.
The 2-mm trocar: a safe and effective way of closing trocar sites using existing
equipment.Reardon PR - J Am Coll Surg - 01-FEB-2003; 196(2): 333-6.
Liu CD, McFadden DW. Am Surg 2000;66:853-4.
Bowrey DJ, Blom D, Crookes PF, et al. Risk factors and the prevalence of trocar site herniation
after laparoscopic fundoplication. Surg Endosc 2001;15:663•.Garzotto MG, Newman RC, Cohen MS, et al. Closure of laparoscopic trocar sites using a springloaded needle. Urology 1995;45:310-2.
Umbilical and epigastric hernia repair. Muschaweck U - Surg Clin North Am - 01-OCT-2003;
83(5): 1207-21
References
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Luijendijk RW, Hop WC, van den Tol P, DeLange DC, Braaksma MM, Ijzermans JN, et al. A comparison of suture
repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392-8
Incisional Hernia Repair Millikan KW - Surg Clin North Am - 01-OCT-2003; 83(5): 1223-34
Toy FK, et al Prospective, Multicenter Study of Laparoscopic Ventral Hernioplasty: Surg Endos 1998; 12(7):955-9.
Park, A. Laparoscopic Ventral Hernia Repair. Advances in Surgery. 2004 38-47
Laparoscopic repair of incisional hernias. Cobb WS - Surg Clin North Am - 01-FEB-2005; 85(1): 91-103, ix
Complications of open groin hernia repairs.Stephenson BM - Surg Clin North Am - 01-OCT-2003; 83(5): 1255-78
DeMaria et al Laproscopic intraperitoneal PTFE patch repair of ventral hernia. Surg Endoscopy 2000
Carbajo et al Laparoscopic treatment vs Open Surgery in the solution of major incisional and ventral hernias with
mesh Surg Endosc. 1999
On the Horizion?
• A study by Dubay et al in the anals of surgery June
2004 shows reduced recurrance rates when
abdominals incisions are treated with basic
fibroblast growth factor
• Advances in mesh technology : those such as that
decrease adhesions or those that allow or even
stimulate tissue regeneration or those that have
improved resistance to infection.
• Randomized, Prospective studies that may provide
guidance in choosing the proper procedure based
on patient characteristics.
• Innovations to help those of us on the learning
curve of laparoscopy
Wound matrix deposition over time.
Fibronectin and type III collagen constitute the
early matrix. Type I collagen accumulates later
and corresponds to the increase in wound
tensile strength.
PDS Background
Indications
Extended wound tensile strength required
Absorption (Hydrolysis)
In vivo tensile strength greater than Vicryl and Dexon
Day 14: 74% of tensile strength retained
Day 28: 58% of tensile strength retained
Day 45: 41% of tensile strength retained
Day 180: Complete Suture absorption
Characteristics
Less contamination of the monofilament
Stiffer and more difficult to handle
More expensive than Dexon or Vicryl