Abdominal Pain/Abdominal Mass

Melissa L. Hughes
Scott Q. Nguyen, M.D.
Celia M. Divino, M.D.
Department of Surgery
Mount Sinai School of Medicine
 HPI Mrs.Masseo

• Mrs. Masseo is a 63-year-old female with

PMH of HTN, DM, s/p laparotomy for
peptic ulcer disease seven years ago
• Presents to ER with one day history of
sudden, worsening abdominal pain
associated with nausea, two episodes of
vomiting, and abdominal distension
 What other information would
you want regarding this patient’s
history?
 Other Pertinent HPI
• Patient had noticed a bulging from her mid abdomen
beneath the surgical scar for the past several months. It
was not initially painful, became larger when she
coughed, and would go away when she was lying down
• After an acute coughing episode the morning prior to
admission, patient reported that she suddenly experienced
severe pain in her mid abdomen that was constant and
accompanied by an increase in size of the midline bulge
which did not go away when she tried to lie down
• No flatus or bowel movement over the past day, several
episodes of vomiting, and subjective fevers
 Other Pertinent History
• PMH: Poorly controlled HTN and DM for
the past 20 years
• PSH: Appendectomy at age 35, laparotomy
7 years ago for PUD
• Meds: lisinopril, insulin, nexium, aspirin
• Allergies: NKDA
• Social history: 1.5 packs of cigarettes a day
for the past 40 years
What would you look for on
physical exam?
 Physical Exam
• Ill-appearing, obese woman in severe pain
• BP 100/60 HR 115 Temp 38.2 C RR 24
• HEENT: oral mucosa dry
• Heart: tachycardic, regular rhythm
• Lungs: clear to auscultation bilaterally
• Abdomen: obese abdomen, healed midline laparotomy
and RLQ scars, hypoactive bowel sounds, moderate
distension, firm, tender softball size mass at midline
scar with erythema of the overlying skin. No rebound
or guarding in remaining abdomen
• Guaiac positive stool
What is your differential
diagnosis?
 Differential Diagnosis

• Incarcerated ventral hernia

• Small/large bowel obstruction- secondary to

adhesions, volvulus, neoplasm

• Abdominal wall tumor

• Abdominal wall abscess

What labs would you order?
 Lab results, Mrs. Masseo
10
134 94 40
15 350 190

30.1 3.3 20 1.7

n% 89

LFTs, amylase, lipase, and coags- WNL

 Lab Findings

• Pre-renal azotemia secondary to

dehydration

• Leukocytosis from infection/inflammatory

process
What imaging would you like to
obtain?
Obstructive Series
 Obstructive Series

Describe the X-ray findings

 Xray Interpretation

• No free air noted on CXR

• No significant small bowel dilatation
• Air in right colon
• No small bowel obstruction
 If this patient had bowel obstruction
secondary to an incarcerated loop of
small bowel in the ventral hernia, then
why are there no signs of small bowel
obstruction on Xray?

Is there another study which may help?

CT Scan Mrs. Masseo
 CT Interpretation

• Transverse colon incarcerated in ventral abdominal

wall hernia
• Soft tissue stranding in subcutaneous fat around
incarcerated hernia
• Absence of enteric contrast past area of incarceration
with collapse of left colon consistent with complete
large bowel obstruction
What would be your next step in
management?
 Hospital Course
• Immediate resuscitation with IV fluids, foley catheter, NG
tube decompression and pre-op antibiotics
• Patient taken to the OR for incarcerated hernia with
suspected strangulated bowel
• Exploratory laparotomy performed using previous midline
incision
• Found to have ischemic loop of transverse colon twisted
upon itself, herniating through a 4cm abdominal wall defect
• Segment of ischemic bowel was resected and primary
anastomosis performed
• Hernia repaired primarily, skin was left open
 Hospital Course

• Patient did well post-operatively without

complications
• POD #4: regained bowel function
• POD #6: tolerated normal diet
• POD#7: discharged home
 What is the problem with
repairing this patient’s hernia
primarily? Would you want to
use mesh in this situation?
Primary repair of Ventral (Incisional) Hernia

• Recurrence of a ventral hernia is a common

problem in primary suture repair, whereas repair
with prosthetic mesh often has lower recurrence
rates
• However, in a patient with strangulated, ischemic
bowel who undergoes a bowel resection, inserting
mesh into a contaminated field increases risk of
infection of the mesh and ultimate need for
reoperation and removal
 Follow-up

• Patient seen at follow-up appointment

6 months later and was found to have
another reducible hernia through the
same 4cm abdominal wall defect
• Patient denied any abdominal pain,
distension, nausea, vomiting, or fevers
What would you do next to help
this patient?
• Discuss treatment options for repair of
recurrent incisional hernias
• Discuss pre-operative preparation
 Follow-up
• Patient taken back to the OR for elective
ventral hernia repair
• Open hernia repair performed using non-
absorbable mesh in an under-lay fashion
• Patient continues to do well two years after
elective repair without any signs or
symptoms of recurrence
 Incisional Hernia Discussion
• Hernias that occur at a prior abdominal incision
site (includes post laparotomy hernias, parastomal
hernias, and trocar site hernias)
• Incisional hernias reported in up to 20% of
patients undergoing laparotomy with modern
rates ranging from 2-11%
• Approximately 100,000 ventral incisional hernia
repairs performed each year in U.S.
• Most present within 12 months post-laparotomy
although as many as 1/3 may present 5-10 years
later
 What are the risk factors for
developing an incisional hernia?
 Risk Factors
• Patient-related factors: advanced age,
malnutrition, diabetes mellitus, cigarette
smoking, corticosteroids, conditions that
increase intra-abdominal pressure like obesity
ascites, or chronic cough
• Surgery-related factors: wound or
intraabdominal infection, closure of abdomen
under tension, type and location of incision
(vertical midline incision more prone to
incisional hernia than transverse), lack of mesh
overlap at hernia edges (bridge technique)
 Clinical Manifestations and Diagnosis
• Bulge in abdominal wall at or near surgical scar
• Discomfort aggravated by coughing or straining
• Enlarges over time leading to pain, bowel obstruction,
incarceration, and strangulation
• In large hernias, the skin may present with ischemic or
pressure necrosis resulting in ulceration
• Usually easy to identify on exam, with palpable edges of
fascial defect
• In obese patients with suspected incisional hernias the
surgeon should have a low threshold for obtaining a CT
abdomen as the clinical exam is very unreliable
 Treatment

• Treatment includes two general types of

operative repair: primary suture repair and
prosthetic mesh repair
• Recurrence rates for non-prosthetic repair
can be as high as 50% or more, whereas
mesh repair is associated with significantly
lower recurrence rates
 Primary Repair
• Usually performed for hernia defects less than 4 cm
in diameter, with strong, viable surrounding tissue
using an interrupted layer of nonabsorbable sutures
• Some studies have suggested that even these small
hernias may have a substantially lower recurrence
rate after mesh repair
• Separation of components is a technique that utilizes
the body’s own tissues for hernia repair, avoids the
use of a foreign body, and in experienced hands may
have very good results
 Prosthetic Repair
• For large hernias, or hernias associated with
multiple small defects, mesh should be placed
by open or laparoscopic approach
• Mesh provides tension-free repair by avoiding
the recreation of tension by fascial apposition.
In large hernias with loss of domain , fascial
apposition may not even be possible.
• Much improved recurrence rates over primary
repair
 Prosthetic Repair
• Many different prosthetic materials available today for
hernia repair but limited evidence and comparative
studies exist
• Bioabsorbable meshes have become popular and may be
used in an infected field but should not be regarded as
permanent hernia repair as high rates of recurrence/
dilatation have recently been described
• Many techniques for mesh placement: (ex) Rives-Stoppa
repair where mesh is placed in retrorectus space,
laparoscopic repair with mesh placement
intraabdominally behind the rectus and peritoneum, open
in-lay, on-lay and under-lay mesh repairs.
• Technique may be paramount in recurrence rates
 Complications
• Recurrence: As high as 30-50% in primary
suture repair, 5-35% in open mesh repair, and
0-11% in laparoscopic mesh repair
• Wound infections are more common after open
repair compared to laparoscopic
• Mesh infection often necessitates removal of
mesh but can occasionally be treated with IV
antibiotics and local wound care
• Erosion of mesh into bowel with development
of enterocutaneous fistulas
• Bowel obstruction/ileus
QUESTIONS ??????
 References
• Feldman LS, et al. Laparoscopic Hernia Repair. ACS
Surgery: Principles and Practice. Chapter 5, Section
28. 2003
• Fitzgibbons RF, et al. Open Hernia Repair. ACS
Surgery: Principles and Practice. Chapter 5, Section
27. 2003
• Townsend CM. Sabiston Textbook of Surgery. 17th
edition
• Zinner, MJ, et al. Postoperative Ventral Wall
(Incisional) Hernia. Maingot’s Abdominal Operations.
Chapter 5. Hernias. 11th edition
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