1. From the Rooter to the Tooter: Common GI Hernias Tony Weaver, D.O. Surgery 2/27/16 @DrTonyWeaver www.drtonyweaver.com

2. Disclosures I have no professional, ethical or financial, disclosures to report. I WISH THAT I DID!!

4. Objectives Define a hernia. Describe the presentation of common hernias. Describe a hernia emergency. Review the diagnosis and treatment of common hernias. Be able to differentiate a hernia from a diastasis recti.

5. What do these 2 have in common?

6. What do they have in Common?

7. Incidence and Epidemiology 10% of the population develops some type of hernia. >1 million abdominal hernia repairs are performed each year, with inguinal hernia repairs constituting nearly 770,000 of these cases Hernias of all types are second only to adhesions as the most frequent causes of obstruction in western countries.

9. Hernia Lingo Reducible Incarcerated Strangulated Sliding Hernia

10. A rose by any other word would smell as sweet ….. Hernia Latin word for “rupture,” is a protrusion of abdominal cavity contents beyond their inherent domain. HERNIA = DEFECT

11. Abdominal Wall Layers

12. Common Hernias Inguinal 75% Femoral 3-5% Incisional/Ventral 10% Umbilical 14% Hiatal Other Rare Hernias

13. Evaluating a Hernia A 55 yo male with a history of groin pain which started abruptly after lifting some boxes 4 hours ago. He has associated nausea, one episode of vomiting and He noticed a painful a bulge. He has a history of a open prostatectomy last year. His HR is 130 on abdominal exam is + extreme TTP & discoloration over the hernia site.

14. This is a Hernia Emergency Urgent Surgical Consultation

15. Work Up Physical Exam findings? Diagnostics? Labs? Treatment?

16. Symptoms Non-Obstructive Intermittent Aching Pain Sharp Shocking Pain Weakness Bulge Appears & Disappears Obstructive ●Constant worsening Pain ●Inability to stand Upright ●Nausea and Vomiting ●Severe Diffuse Abdominal Pain ●Discoloration of Skin overlying the bulge Persistent Nausea and Vomiting is a worrisome sign.

17. Diagnostics Radiology Plan Films CT US Labs CBC BMP Lactate ABG

18. Factors that Lead to Hernias Weakened tissue Smoking Age Steroids Immunosuppressive Meds Collagen disorders Surgical Wounds Force applied to tissue ●Heavy lifting ●Obesity ●Constipation ●Coughing Difficulty urinating

20. Inguinal Hernias a defect or weakness in the transversalis fascia 90% of all inguinal hernia repairs are performed on males MC Type is Indirect. Types Direct Indirect Pantaloon hernia – direct and indirect components

21. Femoral Hernia 1 in 20 Groin hernias are femoral Frequently become incarcerated or strangulated. Bulge in Medial Thigh Perihernial fasciae or muscles may be malformed. More common in women than men Remains 2nd most common behind Inguinal Hernia Approach to repair is the Same

22. Umbilical Hernia Incidence of congenital UH 25% to 50% in black infants and 4% to 9% in white infants More Common in premature infants, a familial inheritance. Age and size of the defect are the most important factors determining spontaneous closure rate. Most spontaneously close by 2-3 yo. Skin ulceration or an episode of incarceration should prompt earlier repair.

23. Ventral Incisional Hernia An incisional hernia is an iatrogenic condition that occurs in 2-10% of all abdominal operations. Secondary to breakdown of the fascial closure of a surgical Recurrence rates approach 20-45%. Poor Operative technique Very Likely to Recur

24. Hiatal Hernias

25. Treatment Options Reduction Observation Support (truss, binder) Repair

26. Reduction RP3 Relaxation Position Patience Persistence

27. Factors to Consider Before Repair ●Location of Placement ●Size of hernia defect ●Location of hernia ●# of hernias ●Patient Comorbidities ●Experience of Surgeon

28. What are the Surgical Techniques used for Hernia Repair? Open Repair Multiple Methods Laparoscopic Repair TAP VS TEP Mesh is Always the best option.

30. Surgical Tx-Umbilical/Epigastric Primary vs Mesh -<2cm can perform primary repair ->2-3 cm perform mesh repair Deysine->40% recurrence without mesh Sarjay->11% recurrence without vs 0% with Schumacher->BMI 30=32%

31. Complications Acute: Seroma/hematoma Urinary Retention Bladder injury Superficial wound infection Chronic: Groin pain Testicular atrophy/pain Mesh infection Recurrence

32. Complications-Wound infection

33. Complications-Mesh Infection Risk Factors -Lap vs Open -Type of Mesh Diagnosis Treatment -Superficial -Deep

34. A case of mistaken Identity….. Diastasis Recti

35. An indirect inguinal hernia is repaired laparoscopically by stapling polypropylene mesh over the defect. The complication of this repair most frequently associated with significant postoperative pain is A. formation of a hydrocele in the sac B. recurrence of the hernia C. erosion of the mesh into the intestine D. entrapment of the ilioinguinal nerve E. entrapment of the lateral femoral cutaneous nerve

36. E. Entrapment of the lateral femoral cutaneous nerve