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Abdominal Wall Hernias Hernia Definition: A hernia is an abnormal protrusion of a viscus through the wall of a cavity which normally contains it. It may be through a congenital/acquired opening in the presence of continued or repeated intra-abdominal pressure Types of Hernias Direct inguinal hernia Indirect inguinal hernia Femoral hernia Obturator hernia Sciatic hernia Perineal hernia Umbilical hernia Paraumbilical hernia Epigastric hernia Hiatus hernia Diaphragmatic hernia Incisional hernia Spigelian hernia Development of a hernia In young age group: congenital potential space In old age group: gradual onset and slow enlargement due to weakness in the abdominal wall Predisposing factors Congenital defect, e.g. persistence of processus vaginalis incomplete obliteration of umbilicus persistent communication between abd. and thorax • Acquired defect, e.g surgical incisions muscle weakness due to ageing/ nerve injury and wasting/ fatty infiltration/ pregnancy Precipitating factors Chronic cough constipation straining at micturition childbirth vomiting severe muscular effort ascites - fluid may increase the size of an existing sac Contents in a Hernia Usual: omentum, small bowel Sliding hernia: content with partial peritoneal cover such as: sigmoid colon, urinary bladder Ritcher’s hernia: part of the small bowel wall was in the hernia with perforation but no obstruction The contents of the sac Reducible irreducible obstructed, or strangulated Anatomy ILIUM ILIUM SACRUM The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle Site / Origin Inguinal Inguino-scrotal Isolated in scrotum Groin hernias indirect inguinal direct inguinal femoral Nyhus Classification Type I--indirect inguinal hernia •Internal inguinal ring normal (i.e. paediatric hernia) Type II--indirect inguinal hernia •Dilated internal inguinal ring with posterior inguinal wall intact Type III--posterior wall defects •Direct inguinal hernia •Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e. massive scrotal, sliding hernia) •Femoral hernia Type IV--recurrent hernia Inguinal Hernias - Anatomy Indirect inguinal hernia most common in young males enters the inguinal canal through the deep ring the sac often extends, following the line of the spermatic cord (over the pubic crest) into the scrotum the neck of the sac is narrow Direct inguinal hernia Common in older men with weak abdominal muscles Often bilateral the sac bulges forward thro’ the posterior wall of the inguinal canal, medial to the inferior epigastric vessels Does not extend into scrotum the neck of the sac is wide Femoral hernia Less common than inguinal hernias occur more frequently in females the sac descends thro’ the femoral ring and canal, thro’ the saphenous opening of the fascia lata. Blunts the groin crease (both types of inguinal hernia increase the crease) it has a narrow neck Main Points in History Age: young or old? Factors for increase abdominal pressure Started with a smaller swelling Disappears on lying down Gurgling noise inside the swelling Pain and dragging discomfort Intestinal obstruction Physical Examination Three important steps MUST be taken Patient standing for the examination - cough impulse and cannot get above the swelling Lying down to reduce the hernia by patient Try to hold back the hernia with the thumb at the internal ring while standing will distinguish direct from indirect inguinal hernia Anatomical Landmarks Anterior superior iliac spine Pubic tubercle Inguinal ligament Mid-inguinal point Interrnal inguinal ring To distinguish direct/indirect hernia Examination of the patient with a hernia With the patient supine look for signs of systemic toxicity intestinal obstruction or inflammation of the abdominal wall visible bulge, effect on groin crease and a visible impulse on coughing allow the patient to attempt reduction of the hernia in the supine position palpate for cough impulse in the area of abdominal wall weakness, note any tenderness Reducible hernia; place a finger over the deep ring and allow the patient to stand ask the patient to hold nose and blow if the hernia appears after release of your finger, then it is an INDIRECT inguinal hernia Scrotal Masses Can you get ABOVE the swelling? Where is the mass arising from? The mass itself cystic/transilluminate? The mass hard and the surface irregular? Scrotal swellings Painful + firm Painless + firm Torsion Acute inflammation (orchitis/ epididymitis) Neoplasm Chronic inflammation haematoma Soft Varicocele Hydrocele Epididymal cyst Varicocele Grade 1 - palpable with Valsalva Grade 2 - palpable without straining Grade 3 - can be seen on inspection Bag of worms in 15% of young man More common on the left side 30% infertile patients have varicocele Varicocele Usually cause discomfort after running Spermatogenesis impaired due to hypoxia, elevated temperature and reflux of metabolites Treatment by Ligation of the veins Varicocele in older man may indicate left renal carcinoma with renal vein involvement Torsion of Testis To distinguish from Orchitis Both are acute painful swelling of the testis Treatment is different Age, fever, venereal exposure… Types of torsion - extra-vaginal, intravaginal, Torsion of the undescended testis Empty Scrotum Undescended testis Ectopic testis Retractile testis Hydrocele Accumulation of fluid in the tunica vaginalis Short history - thin wall and transilluminate Long history - thick wall and ?previous trauma Cystic mass, the testis is within the sac and therefore NOT palpable Can get above the swelling Surgery - Jaboulay’s operation Trauma to the Scrotum Haematocele of the testis Rupture of the testis Fracture of the penis Trauma to the bulbous urethra Laceration of the scrotal skin Testicular Tumour Hard and irregular swelling of the testis Spermatic cord normal Types - germ cell, non germ cell, secondary metastasis, paratesticular tissues Must palpate the abdomen for central supra-umbilical masses (lymph nodes) Indication for Surgery Risk of complications such as strangulation and intestinal obstruction Pain and mass interfere with function Conservative treatment Principles of Surgery Reduction of the contents Excision of the hernial sac Repair of the defect Difficult in case of large hernia and large defects Historical developments 1700 BC: Hammurabi (Babylon) – Hernia reduction / bandaging 1363 : Guy de Chauliac – Distinguished inguinal from femoral hernia for the first time in Chirugia Magna 1. 2. 3. Reinforcing the anterior wall and narrowing the external ring Eg Repair by ligation of hernial sac and cicatrization with healing by secondary intention (Caspar Stromayr, 1559) Reinforcing the posterior wall and narrowing the internal ring 1881 Splitting of external oblique + ligation of sac at internal ring (Lucas-Championnière) 1889 Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis fascia) to inguinal ligament (Bassini) 1939 Subcutaneous shift of spermatic cord (Kirschner) 1969 Duplication of transversalis fascia (Shearburn – as per Shouldice) 1987 Application of alloplastic material (Lichtenstein) Reinforcing the posterior wall and narrowing the internal ring from intraabdominally 1891 During laparotomy for other indication (Tait) 1990 Laparoscopic hernia repair (Popp) Hernien Open hernia repair Bassini Shouldice Lichtenstein Robbins-Rutkow Prolene Hernia System CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN Repair under Tension 1889 Bassini - Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis fascia) to inguinal ligament Tension created during repair with recurrence rates generally around 10% Best results reported by Shouldice using his technique in a dedicated hernia hospital – recurrence of only 0.8% Hernioplastik n. Bassini Bassini CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN Hernioplastik n. Shouldice Shouldice CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN Hernioplastik n. Lichtenstein Lichtenstein CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN Preperitoneal Approach Originally described by Stoppa Mesh placed between peritoneum and abdominal wall Precursor to laparoscopic repair techniques The Lichtenstein Technique Mesh repair popularised by Lichtenstein – published a series of 1000 patients with no recurrences in 1-5 yr follow-up Mesh repair for ALL hernias Local anaesthetic Day case surgery Same day ambulation Am J Surg, 1989. 157 (2): 188-93 Lichtenstein Hernia Repair Local anaesthetic Prolene Hernia System Hernien Laparoscopic hernia repair TEP (total extraperitoneal plasty) TAPP (transabdominal preperitoneal plasty) CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN TEP - total extraperitoneale Hernioplastik TEP (mesh between fascia transversalis and peritoneum) CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN TAPP - transabdominelle praeperitoneale Hernioplastik TAPP (mesh between fascia transversalis and peritoneum) CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN Hernien Complications Relapse (no mesh: 10% - 20 %, mesh: ~ 2%) Hematoma (10%) Wound infection (< 5%) Chronic pain (< 5%) Scrotal edema with or w/o orchitis (< 2%) CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN Plug and mesh Claimed advantages: Evidence from trials: Decreased operating time Smaller incisions Low recurrence rates Little difference in operating times Recurrence rates 0 – 2% No difference in post-op pain / rehab Review (ANZ J Surg, 2002, 72: 573-9): No strong evidence for benefits over traditional mesh repair Preperitoneal Approach Advantages: Recurrent hernia – different approach avoids operating on distorted anatomy / scar tissue May repair bilateral hernias through Pfannenstiel or midline incisions Complications of Inguinal Hernia Repair Chronic pain Infections Others Chronic pain Persistent pain is the most troublesome complication following inguinal hernia repair Postulated mechanisms: Nerve injury Tension Infection Suture placement Chronic Pain Operative strategies to minimise chronic pain: Avoid placing periosteal sutures on the pubic tubercle Avoid undue tension on the inguinal ligament Careful preservation of ilioinguinal and genitofemoral nerves Strategies to treat chronic post-op pain: Division of ilioinguinal or genitofemoral nerve Removal of mesh / sutures Pain service referral - Tricyclics / anti-depressants Infections Infection rate in inguinal hernia wounds 1-2% Superficial infections more common than deep infections involving prosthesis Operative techniques to avoid infection: Meticulous asepsis Minimise necrotic tissue / diathermy / desiccation Wound lavage Monofilament sutures Perioperative antibiotics ? Topical antibiotics Hiatal Hernia Overview Chronic relapsing condition Significant morbidity Estimated lifetime prevalence of 2535 % 44% have heartburn once a month 14% have weekly symptoms 7 % have daily symptoms Gastroesophageal Reflux Diagnosis History Response to a PPI Radiologic findings Endoscopy Ambulatory pH monitoring History Heartburn, regurgitation High specificity, low sensitivity Atypical Symptoms Atypical chest pain Hoarseness Nausea Cough Odynophagia Asthma Globus sensation Onset after age 45 Recurrent laryngitis Recurrent sore throat Subglottic stenosis Dental enamel loss Complications of Gerd Dysphagia Odynophagia Early satiety GI bleeding Iron deficiency anemia Vomiting Weight loss Response To PPI Omeprazole 40 mg BID X 14 days as specific and sensitive for diagnosis as 24 hour pH monitoring Failure to respond warrants further investigation into patients symptoms Radiologic Findings Only 1/3 of patients have radiologic findings Hiatal hernia Erosions Ulcerations Strictures Thickening of mucosal folds Not the test of choice for diagnosis Endoscopy Useful for diagnosing complications of GERD Barrett’s Esophagitis Strictures Not sensitive for GERD itself Only 50% of patients manifest evidence on endoscopy EGD EGD EGD Ambulatory pH Monitoring Diagnostic gold standard pH monitor placed in esophagus above sphincter Patient symptom log Correlate symptoms with low pH Treatment Lifestyle modifications Antacids Histamine H2 receptor antagonists Prokinetic Agents Proton Pump inhibitors Anti-reflux surgery Newer endoscopic treatments Lifestyle Modification Head of bed elevated six inches Decreased fat intake Smoking cessation Weight loss Avoidance of recumbency for 3 hours post-prandially Avoidance of large meals and trigger foods Avoidance of exacerbating medications Dietary Factors Caffeine Spicy foods Peppermint Citrus fruits Fatty foods Tomato products Chocolate Alcohol Antacids Antacids are appropriate initial tx 1/3 of patients use twice weekly More effective than placebo Adverse Effects Of Antacids Aluminum: constipation, hypophosphatemia, osteomalacia Calcium: constipation, milk-alkali syndrome, rebound hyperacidity Magnesium: diarrhea, accumulation in pts. with renal impairment Sodium bicarb: milk-alkali in high doses Mag-Aluminum: minor changes in bowel function H2 Blockers 70% with reported relief within 2 weeks of initiating treatment faster healing rates in patients with erosive esophagitis compared with placebo Higher dosages increase effectiveness Prokinetic Agents Do not neutralize acid Increase both gastric emptying, improve peristalsis and increase lower esophageal sphincter pressure Side-effects: abdominal cramping, diarrhea, prolonged QT and fatal arrhythmias Proton Pump Inhibitors Failure of twice daily H2 blockers 83% of patients showed improvement with PPI vs 50% with H2 blocker For erosive esophagitis, faster healing rates than H2 blocker At one year, pts tx’d with daily PPI less likely to relapse No significant difference between the PPIs Potential Long-term Complications Hypergastrinemia, gastric carcinoid tumors in rats Atrophic gastritis with use of prilosec > 5 years—potential development of gastric CA Increased risk of enteric infections— campylobacter Vitamin B malabsorption Antireflux Surgery Indications Failed medical management Patient preference for surgery despite successful medical management Complicated GERD Large Hiatal Hernia Atypical symptoms with reflux documented on 24-hour pH monitoring Surgical Candidates Reflux esophagitis documented by EGD Normal esophageal motility by manometry Should have at least a partial response to trial of acid suppression therapy Basic Tenets Of Surgery Reduction of hiatal hernia Repair of diaphragmatic hiatus Strengthening of the GE junctiondiaphragm attachment Strengthening of antireflux barrier though gastric wrap around GE junction (fundoplication) 75-90% effective at alleviating heartburn and regurgitation Surgical options for hiatal hernia Nissen fundoplication Collis gastroplasty Partial fundoplication Burma gastropexy Nissen Fundoplication Collis Gastroplasty 240o Partial fundoplication Belsey Mk IV Post-surgical Complications Solid food dysphagia: 10% Gas/bloating: 7-10% Diarrhea, nausea and early satiety: < 10% Within 3-5 years, 52% of patients taking antireflux meds again New Endoscopic Treatments Stretta procedure: radiofrequency heating of GE junction Endoscopic gastroplasy (endocinch) Less costly than conventional surgery Initial studies show decreased or eliminated use of acid suppressant meds in 50-75% of patients Incisional Hernia Any laparotomy associated with incisional hernia rate of 14% Technical failure in closure: tension, bites, layers Associated factors Obesity Infected case/wound Diabetes Multiple operations malnourished Genetically predetermined:collagen defect Types of Surgery Onlay Sublay Inlay „Sublay” Mesh Insertion Technique Anterior layer of rectus abdominis sheath Rectus abdominis Mesh Posterior layer of rectus abdominis sheath Peritoneum „Onlay” Mesh Insertion Technique Mesh Anterior layer of rectus abdominis sheath Rectus abdominis Posterior layer of rectus abdominis sheath Peritoneum „Inlay” Mesh Insertion Technique Anterior layer of rectus abdominis sheath Rectus abdominis Posterior layer of rectus abdominis sheath Mesh Peritoneum Bibliography 1. 2. 3. 4. 5. 6. 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