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PBEI Incisional Hernia PDF
PBEI Incisional Hernia PDF
Incisional Hernia
2
Definition
Protrusion of an organ through
the wall that normally contains it. Ventral
hernia occurs in the
abdominal wall. Incisional hernia occurs in
the
area of an old surgical scar.
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Etiology
➢ Mechanical Factors – Intraabdominal
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.
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Risk Factors
Age Above 65 or 70 Male Gender
Malnutrition Sepsis Anemia Uremia
Ascites / Liver Failure Diabetes Pulmonary
Disease Smoking
Abdominal Distension BMI > 30 Coughing
/ Retching Urinary Retention Post-op Ileus
Peritoneal Dialysis Wound Infection
Corticosteroids Chemotherapy
Immunosuppression
Surgical Risk Factors
Surgical risk factors: midline incision Suture
materials: slowly absorbable and
non-absorbable suture
materials.
➢ Non- absorbable suture materials, associated
with
increased wound pain and sinus formation.
Suture Technique Ideally, tensile strength
should be maintained
during the healing process of the wound.
Mass closure vs layered Closure.
➢ Layered closure results higher hernia and
dehiscence
rates. Continuous vs. Interrupted Sutures.
➢ Continuous suture: faster, easier, and can,
thus, save
operating time.
SMALL BITES VS LARGE BITES
TECHNIQUES
Hernia surgery, current principle; 2016
Suture 2.0, HR 36
5 mm
5 mm
Fascia
Fascia edge
Intraabdomen
Suture technic
Simple rule, the length between stitches must not
exceed the distance between the fascia edge and the
stitch.
Hernia surgery, current principle; 2016
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Clinical Presentation
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 11
Presentation and Workup
Physical exam may not be
adequate in obese patients. CT should be
used to find a recurrence or associated
pathologies MRI can be used to find
postoperative adhesions
Surg Endosc (2014) 28 : 2-29
Repair Hernia: Open vs Lap. 12
Principes of success
Patient Technique Prostetic
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Open repair:
Extensive soft-tissue
dissection. Limited to visualize of the
abdominal wall. Difficult to obese patients.
Recurrence rate. LOS. Pain. Wound
complication.
Laparoscopic repair:
Minimization of soft-tissue
dissection. To visualize much of the
abdominal wall leads to fewer missed hernias.
In obese patients. Recurrent hernia. Wound
complication. Recurrence rate. LOS. Pain.
With 14
mesh vs without mesh
Primary repair without mesh For defect < 20
mm Recurrence rate: 54-63%
Primary repair with mesh For defect >= 20 cm
Recurrence rate: 32%. Iatrogenic enterotomy
: 1.2% Mesh infection : 1% Seroma complete
formation resolution : 100% after (30% 90 days)
become symptomatic,
Surg Endosc (2014) 28 : 2-29
Prostetic 15
Prostetic (Mesh) (Mesh)
IPOM : only materials approved for use in the
abdominal cavity should be used (PTFE, PVDF,
composite meshes with absorbable barrier coated and
composite meshes with permanent barrier coated)
Because the biologic interaction between mesh material
and patient could
not be predicted, all patients should be informed about the
risk of potential interactions and complications.
Laparoscopic IPOM (sizes from 880 up to 1.250 cm2) is
feasible for :
▪ Obese patients (BMI > 30)
▪ Defects larger than 15 cm
Characteristics of ideal mesh :
•Minimal adhesion formation
•Excellent tissue ingrowth
•Minimal shrinkage
•No infection or fistula formation
•Minimal pain
•Minimal seroma formation
•No change in abdominal wall compliance
•Low price
•Easy to manipulate
Surg Endosc (2014) 28 : 2-29
16
Laparoscopic transperitoneal and total
extraperitoneal
preperitoneal / sublay repair are surgical options
for the cure of small- and medium-sized ventral
and incisional hernias. For lower abdomen,
both techniques require more experiences ECS
(Endoscopic component separation) technique,
Rosen
2007, combined with both techniques, could be
done for very large incisional hernia.
Laparoscopic Technique
Set 17
Up and Trocar Sites
Left or right upper quadrant subcostally
is recommended for 1st access port. Use
30° laparoscope The trocar entry points should
be as far
as possible from the adhesion site/defect
location (approx. 16-18 cm), and should be
placed to achieve triangulation of the hernia site.
Visually guided entry of trocars is
recommended because these decrease the size of
the wound
Surg Endosc (2014) 28 : 2-29
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Adhesiolysis Adhesiolysis
Adhesiolysis offers no additional benefit in itself, should
be limited to freeing the abdominal wall to enable
adequate overlapping of the defect by the mesh.
Cold and sharp adhesiolysis is preferred to
ultrasonic dissection.
Bipolar coagulation is allowed, but
monopolar should be avoided.
Adhesiolysis should be performed near the abdominal
wall away from the adherent bowel.
Surg Endosc (2014) 28 : 2-29
19
Mesh Attachment
The margins of the defect
may be marked on the skin. The patch is
measured and
trimmed to fit. Overlapping 3-4 cm. 4-6
large fixation sutures are placed around the
patch and tied.
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Currently : Currently :
Karl LeBlanc (1993) : bridging repair (classic
IPOM : metallic tack +
mesh-fixing sutures) decreased recurrence
rate from 9% to 4%. Bridging repair may
causes functional problem in larger hernias.
Augmentation repair (IPOM-Plus : transfascial
closure of defect + IPOM) reduces the
recurrence rate, seroma formation, and
incidence of chronic pain. Mesh overlapping 5
infraumbilical defect and 8 cm with
augmentation repair.
Surg Endosc (2014) 28 : 2-29
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Mesh Insertion
Mesh Fixation 22
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Mesh fixation
Method used for fixation : sutures and/or
tacks. Suture fixation : longer operation time.
Tacks : higher rate of mesh shrinkage.
Additional glue may increases the efficacy of
fixation
and postoperative pain.
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