Objective : 5 Taylor Vaughan Case #2: Mr. Lewis Objective : 5 Taylor Vaughan

If it’s hard talking to strangers, sounds like we may not need the Viagra… Just talk to more strangers Doc, it’s really hard talking to a complete stranger about this, but I think I might need Viagra

Objectives Categorize different types of hernias Describe management of reducible vs incarcerated hernias Summarize causes and management of postoperative ileus

Definitions Hernia – protrusion of organ/tissue through wall defect Incarcerated – unable to be reduced Strangulated – blood supply to enclosed bowel has been compromised

Inguinal Hernias 75% of all hernias 1/3 direct 2/3 indirect

Direct Inguinal Hernia Bowel travels through abdominal fascia → external inguinal ring Medial to inf. epigastric vessels More common in older individuals

Indirect Inguinal Hernia Bowel travels through internal ring → external ring Lateral to inf. epigastric vessels Via patent processus vaginalis

Management Algorithm Reducible Incarcerated Asymptomatic Symptomatic Elective Repair Observation Exquisite tenderness Peritoneal signs Emergent repair

Repair 700,000/yr in the US Herniotomy – removal of hernia sac -rrhaphy – hernia sac removal with defect pathway obliteration -plasty – repair with autogenous or autologous material

Other Hernia Types Ventral Hernias Incisional – midline in people predisposed to poor wound healing Umbilical – often congenital Observe unless >5yo or >2cm

Other Hernia Types Femoral Hernias Bulge below inguinal ligament Female>Male 2:1 Commonly strangulate → Repair

Post Operative Ileus (POI) “Loss of intestinal peristalsis in the absence of mechanical obstruction”

Pathogenesis Inhibitory neural reflexes Inflammation Increased sympathetic tone Inflammation Injury→macrophages→COX2/PG→ decreased intestinal contraction Neurohumoral peptides NO, VIP, Sub P – inhibitory GI NTs Opioids ↑ resting tone, ↓ gastric motility, ↓ colonic propulsion

Evaluation Ileus is often normal/physiologic Abdominal XR Vitals/Labs Rule out obstruction or foreign body Vitals/Labs Rule out infection or correctable electrolyte disturbance (K / Mg)

Management Gentle diet advancement Midthoracic epidural NG Tube?? Blocks nociceptive afferents NG Tube?? Chewing gum??

Management Peripherally acting opioid antagonists Don’t effectively cross BBB Block mu-opioid efffects peripherally Maintains central effects… analgesia! Methylnaltrexone (Relistor) Almivopan (Entereg)

References Delaney, CP, Wolff, BG, Viscusi, ER, et al. Almivopan, for postoperative ileus following bowel resection: a pooled analysis of Phase III studies. Ann Surg 2007; 245:355. Holzer, P. Treatment of opioid-induced gut dysfunction. Expert opin investing drugs. 2007; 16:181. Karthikesalingam, A, Markar, SR, Holt, PJ, et al. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010; 97:4. UpToDate.com (abdominal wall hernias, groin hernias, postoperative ileus) Viscusi, ER, Gan, TJ, Leslie, JB, et al. Peripherally acting mu-opioid receptor antagonists and postoperative ileus: mechanisms of action and clinical applicability. Anesth analg 2009; 108:1811. Wikipedia (hernia, ileus)