Sublay H-shape mesh as a novel technique for repair of para umbilical hernia in obese patients Ashraf I. Obaid, MD, PBGS, Karam M. Alslaibi, MD Presented By Dr. Karam M. Alslaibi Department of General Surgery III in Shifa Medical Complex April 2017

Presentation Outline Introduction Objective Methodology Results Comparison with others Conclusion

Introduction Para umbilical hernia. Risk Factors. Methods for repair.

Introduction cont… 4% suture repair 10-30%. 10.7% Based on literature review, the suture repair for PUH resulted in a high recurrence rates 10-30%. The use of different kind of meshes can reduce this rate up to 4%. (Rituraj et al., 2016). Higher patient’s body mass index >30 kg/m2 and hernia size of >2 cm are risk factors for para umbilical hernia recurrence. Usage of suture repair in obese patient make the recurrence rate reach 18.3% (ANJUM et al., 2012). Even with use of mesh, the recurrence rate in obese patient can reach 10.7%. (Linas Venclauskas et al., 2008). Obese patients + mesh Non obese patients + mesh 4% suture repair 10-30%. 10.7%

Introduction cont… Generally, the treatment of ventral hernia has changed drastically over the last 20 years. However, there is still some controversy concerning mesh positioning & operation methods.

Objective To assess validity of sublay H shape mesh as a novel technique in repair of PUH in obese patients in terms of complications and recurrence.

Patient Selection Criteria Methodology Patient Selection Criteria Including criteria: All patients with PUH and BMI >30 kg/m2 Hernia size >2 cm.

General Considerations Methodology General Considerations All patients were operated by using sublay H-shape mesh technique. The size of mesh used was variable depending upon the size of the defect, mostly 10*8 cm size was used. In this technique, polypropylene mesh was used to repair the defect.

Methodology Surgical Technique The hernias were repaired using a 6– 7-cm mid-midline incision The hernial sac was identified and left in situ and reduced. Elliptical incision around the defect on anterior rectus sheath. (Radius: 2- 3cm in horizontal direction and 3- 4cm in vertical direction). Eversion of 2 flabs of anterior rectus sheath to close the hernial defect and stitch them with vicryl 0. 2-3 cm 3-4 cm

Methodology Surgical Technique Dissection underneath the rectus muscle for preparing to put the mesh. Making H-shape mesh and fix it in the midline above flabs, the 4 limbs were placed under the rectus muscle with at least 2cm up and down. A subcutaneous hemovac drain was used in all patients & the skin was closed with absorbable subcuticular vicryl. The operative, post operative complications and quality of life following surgery were all noted. Recurrence was diagnosed during follow up period, which was on average 36 months after discharge from the hospital. ≥ 2 cm

Results & Discussion

Result Results Gender

Additional Information Results Additional Information Value Element 41-63 year Age group 38.5 kg/m2 Average BMI 36 months Median follow up

Results Complications

Comparison between current and other methods for repairing of PUH Ref. Recurrence Wound infection Seroma hematoma Average follow up Median BMI Number of pt. Method of repair Type of hernia Location (Rituraj, 2016) 10.3% 1.5 % ? 12 months 31.5 kg/m2 68 patients Simple Suture Repair (mayo’s) PUH Jaipur (India) (Daudpoto, 2013) 2.7 % 11.1 % 2.7% 30 months <30 kg/m2 36 patients Onlay mesh Karachi (Pakistan) (L.Venclauskas, 2008) 10.7% 2.1% not available >30 kg/m2 97 patients Kaunas (Lithuania) Current Study none 8.3% 16.5% 36 months 38.5 kg/m2 12 patients Sublay H shape mesh Gaza

Conclusion A lower incidence of postoperative seromas, hematomas, infections, and other related complications is observed after using Sublay H- shape mesh technique for repair of PUH. No recurrence rate is noted after repair of obese patients with this new technique. According to our results, Sublay H-shape mesh technique can be used as a preferred choice of operation in obese patients with PUH.

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