1. CASE MANAGEMENT - PRESENTATION AND DISCUSSION ON INCISIONAL HERNIA BY Harvey A. Balucating, MD Department of Surgery Ospital ng Maynila Medical Center

2. R.C, 58/M FROM TONDO, MANILA CHIEF COMPLAINT: BULGING ABDOMINAL MASS

3. HISTORY OF PRESENT ILLNESS: 2 yrs PTA  Px underwent ‘E’ Exploratory Laparotomy, duodenorrhapy, omental patching sec to Perforated PUD. 22 months PTA  noted bulging abdominal mass, about a size of a fist. Most noticeable during straining or prolonged standing, reduced sponataneously on recumbent position. (-) episode of vomiting (-) episode of vomiting (-) changes in BM (-) changes in BM Gradual increase in abdominal mass prompted Consult at OMMC and subsequent Admisssion Gradual increase in abdominal mass prompted Consult at OMMC and subsequent Admisssion

4. PAST MEDICAL Hx: –s/p ‘E’ Ex-Lap, duodenorrhaphy, omental patch for Perforated Peptic Ulcer Disease – OMMC – July 2004 –No Hypertension –No DM FAMILY Hx: No heredofamilial disease PERSONAL/SOCIAL Hx: smoker, 20 pack-years, stopped last 2004 occasional alcoholic beverage drinker

5. PHYSICAL EXAMINATION: BP= 120/80 CR=89 RR= 20 T=36.5 HEENT: pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPC C/L: SCE, no retractions, clear BS HEART: adynamic precordium, NRRR, no murmur

6. ABDOMEN: Flabby, NABS, soft, non- tender (+) healed midline incision (+) mass, soft, non- tender, reducible, around the umbilicus with fascial defect approx 8 x 8 cms around the umbilicus (+) mass, soft, non- tender, reducible, 6 cms above the umbilicus with fascial defect approx 2x2 cms.

7. EXTREMITIES: full equal pulses, No edema

8. Salient Features: 58 y/o, M 2-yr History of bulging abdominal mass, reducible Fascial defect approx 8 x 8 cms and 2 x 2 cms History of previous operation

9. BULGING ABDOMINAL MASS Hernia Non-Hernia Hernia Non-Hernia Incisional Epigastric Intra-peritoneal Abdominal hernia hernia wall hollow solidSkin SubQ Muscle hollow solidSkin SubQ Muscle viscus organ viscus organ Umbilical Umbilical hernia hernia

10. Clinical Diagnosis: DiagnosisCertaintyTreatment Incisional Hernia without obstruction or gangrene 99%Surgical Incisional Hernia with obstruction or gangrene 1%Surgical

11. Do I need a para-clinical diagnostic procedure? NO NO

12. BASIS: Patient with history of on and off bulging mass on incision site, s/p ‘E’ Exploratory Laparotomy will give us a diagnosis of Incisional Hernia with 99% certainty.

13. Pretreatment Diagnosis DiagnosisCertaintyTreatment Incisional Hernia without obstruction or gangrene 99%Surgical Incisional Hernia with obstruction or gangrene 1%Surgical

14. TREATMENT PRETREATMENT DIAGNOSIS: Incisional Hernia without obstruction or gangrene s/p…

15. TREATMENT GOALS OF TREATMENT: - reduce hernial content - repair the fascial defect - prevent recurrence of incisional hernia after the repair

16. TREATMENT OPTIONS TREATMEN T BENEFITRISKCOSTAVAIL Simple non- prosthesis repair Ease in repair, shorter OR time 25-55% recurrenc e rate 1 OR cost available Incisional herniorrhaph y with mesh (Sublay Prosthesis repair) Relatively lower recurrence rate 1-20% recurrenc e rate Prosthesi s-related infection (5%) 2 OR cost + P6,00 0 available 1. Korenkov et. al., Langenbeck’s Arch Surg, 2000 1. Korenkov et. al., Langenbeck’s Arch Surg, 2000 2. American College of Surgeons, 2004 2. American College of Surgeons, 2004

17. TREATMENT OF CHOICE SUBLAY PROSTHESIS REPAIR

18. PREOPERATIVE PREPARATION Informed consent Psychosocial support Optimize patient’s health Screen for any condition that will interfere with treatment Prepare materials 1. Prolene Mesh

19. OPERATIVE TECHNIQUE Patient supine under CLEA Asepsis/Antisepsis Sterile drapes Excision of scarred incision skin Subfascial flap dissection separating rectus from peritoneum/hernial sac Hernial sac opened

20. OPERATIVE TECHNIQUE cont.. Inspection of intraabdominal organs for gut adhesions and additional fascial defects Silk suture laid on peritoneum for mesh anchoring Interrupted Silk 2-0 sutures approximating small superior fascial defect Excess peritoneum trimmed Closure of peritoneum with chromic 3-0 simple continuous

21. OPERATIVE TECHNIQUE cont.. Mesh laid over the area of larger defect Anchoring sutures tied Closure of fascia with simple continuous suture, Vicryl-0 Hemostasis Running continuous with Vicryl 2-0 subcutaneous Subcuticular Vicryl 4-0 Correct sponge and instrument count Dry Sterile Dressing

22. OPERATIVE TECHNIQUE

23. OPERATIVE FINDINGS 7 cms fascial defect from umbilicus down and 1 cm above Small fascial defect approx 1x1 cms, 6 cms superior to the umbilicus, left of the midline No incarcerated bowel noted

24. OPERATION DONE: Incisional Herniorrhaphy with subfascial prosthesis POST-OP CARE Sufficient analgesia Nutrition Wound care Monitoring of complications and treat as indicated Advice on home care of wound Advice on ff-up plans

25. SHARING OF INFORMATION

26. INCISIONAL HERNIA occur as a complication of previous surgery Causes: 1. poor surgical technique 2. rough handling of tissues 3. use of rapidly degraded absorbable suture materials 4. closure of the abdomen under tension, 5. infection

27. 6. Male sex 7. advanced age 8. morbid obesity 9.abdominal disstention 10. cigarette smoking 10. cigarette smoking 11. pulmonary disease 11. pulmonary disease 12. hypoalbuminemia 12. hypoalbuminemia

28. The incidence of incisional hernia was significantly lower when nonabsorbable sutures were used in a continuous closure; however, the incidence of suture sinus formation (9%) and that of wound pain were significantly higher (MEDLINE and Cochrane database)

29. The best definition is any abdominal wall gap, with or without a bulge, that is perceptible on clinical examination or imaging by 1 year after the index operation. Incidence: 3 – 20% (double if the index operation is associated with infection)

30. Risk: midline - 10.5% transverse - 7.5%, transverse - 7.5%, paramedian - 2.5% Early evisceration is commonly seen among males. Early evisceration is commonly seen among males. Incarceration and strangulation occur with significant frequency, and recurrence rates after operative repair approach 50%.

31. Classification of incisional hernias I. According to localization (modified Chevrel) –Vertical 1.1. Midline above or below umbilicus 1.2. Midline including umbilicus right or left 1.3. Paramedian right or left –Transversal 2.1. Above or below umbilicus right or left 2.2. Crossed midline or not

32. –Oblique 3.1. Above or below umbilicus right or left –Combined (midline + oblique; midline + parastomal; etc)

33. II. According to size –Small (<5 cm in width or length) –Medium (5-10 cm in width or length) –Large (>10 cm in width or length)

34. III. According to recurrence –Primary incisional hernia –Recurrence of an incisional hernia (1., 2., 3., etc. with type of hernioplasty: adaptation, Mayo-duplication, prosthetic implantation, autodermal etc.)

35. IV. According to the situation at the hernia gate –Reducible with or without obstruction –Irreducible with or without obstruction According to symptoms –Asymptomatic –Symptomatic

36. Operative Technique Operative Technique: I. Simple Non-Prosthesis Repair II. Posthesis Repair a. Onlay Prosthetic Repair b. Prosthetic Bridging Repair c. Combined Fascial and Mesh Closure d. Sublay Prosthetic Repair

37. Simple Non-Prosthesis Repair recurrence rate ranges from 25% to 55% According to the experts' recommendation, the fascia-duplication should only be used for small incisional hernias (3 cm or less) and if the reconstruction of the repair is oriented horizontally (Korenkov et al, 2000).

38. monofile non-resorbable material - U- suture by Mayo-duplication or running suture with a suture:wound length ratio of 4:1.

39. Prefascial (Onlay) Prosthetic Implantation (Chevrel-technique) The recurrence rates indicated in the literature vary between 2.5% and 13.3% Authors using this technique estimate the amount of wound healing complications after this operation to range between 4% and 26% and estimate the rate of prosthesis removals between 0% and 2.5%

40. The main disadvantage of the onlay technique is the direct contact of the prosthesis (partly or completely) with the environment during the wound revision, which can cause wound healing complications. "subprosthetic hernia"

41. Subfascial Prosthetic Repair (Sublay Technique) retromuscular approach placement of a large prosthesis in the space between the abdominal muscles and the peritoneum. To date, no controlled study has been published that has tested the sublay technique versus the onlay technique (Korenkov et al, 2000).

42. Recurrence rate 1 – 20% (Korenkov et al, 2000).

43. Choice of Prosthesis Type I. - Totally macroporous prostheses (pores larger than 75 µm) Marlex Monofilament polypropylene Prolene Double filament polypropylene Atrium Monofilament polypropylene

44. Type II. - Totally microporous prostheses (pores less than 10 µm) Gore-Tex Expanded PTFE

45. Type III - Mix-prostheses (macroporous with multifilamentous or microporous components) Teflon PTFE mesh Mersilene Braided Dacron mesh Surgipro Braided polypropylene mesh MicroMesh Perforated PTFE patch

46. Autodermal hernioplasty According to the literature, the recurrence rates of the autodermal hernioplastic and the prosthetic strengthening are comparable

47. Laparoscopic Hernia Repair Laparoscopic incisional hernia repair may be considered for any ventral hernia in which mesh will be used for the repair. Contraindication: suspected strangulated bowel or loss of domain

48. Poor results of Incisional Hernia Repair 1. preexisting comorbid conditions 1. preexisting comorbid conditions 2. cancer-related debilitation 2. cancer-related debilitation 3. morbid obesity 3. morbid obesity 4. use of steroids 4. use of steroids 5. chemotherapy 5. chemotherapy

49. MCQ 1. Contraindication for laparoscopic hernia repair. a. patients with suspected strangulated bowel a. patients with suspected strangulated bowel b. Swiss cheese hernia b. Swiss cheese hernia c. defects in close proximity to the bony margins of the abdomen c. defects in close proximity to the bony margins of the abdomen d. dense adhesions d. dense adhesions

50. MCQ 1. Contraindication for laparoscopic hernia repair. a. patients with suspected strangulated bowel a. patients with suspected strangulated bowel b. Swiss cheese hernia b. Swiss cheese hernia c. defects in close proximity to the bony margins of the abdomen c. defects in close proximity to the bony margins of the abdomen d. dense adhesions d. dense adhesions

51. 2. Incisional hernia wioth fascial gap of 10 x 6 cms is considered: a. Small b. Medium c. Large d. Not enough data to classify

52. 2. Incisional hernia with fascial gap of 10 x 6 cms is considered: a. Small b. Medium c. Large d. Not enough data to classify

53. 3. Predisposing Condition for the development of incisional hernia except: a. emphysema b. deep surgical site infection c. BMI of 24 d. Poor surgical technique

54. 3. Predisposing Condition for the development of incisional hernia except: a. emphysema b. deep surgical site infection c. BMI of 24 d. Poor surgical technique

55. MCR 1. True of Simple non-prosthetic repair of incisional hernia: I. recurrence rate ranges from 25% to 55%. II. If there is a solitary defect 3 cm or less in diameter, primary closure with absorbable suture material is appropriate. III. Less time consuming and assoc with less complication IV. Because of the high recurrence rates, the simple fascia-duplication can no longer be regarded as the "gold standard"

56. MCR 4. True of Simple non-prosthetic repair of incisional hernia: I. recurrence rate ranges from 25% to 55%. II. If there is a solitary defect 3 cm or less in diameter, primary closure with absorbable suture material is appropriate. III. Less time consuming and assoc with less complication IV. Because of the high recurrence rates, the simple fascia-duplication can no longer be regarded as the "gold standard"

57. 5. Which of the ff prosthesis repair is/are true? I. Prefascial prosthesis Implantation: subprosthesis hernia II. Sublay Technique : large prosthesis in the space between the abdominal muscles and the peritoneum. III. Combined Fascial and Mesh Closure: posterior fascia is closed primarily, The anterior fascia is then bridged with a prosthesis IV. Sublay Technique :not suited for swiss-cheese hernia IV. Sublay Technique :not suited for swiss-cheese hernia

58. 5. Which of the ff prosthesis repair is/are true? I. Prefascial prosthesis Implantation: subprosthesis hernia II. Sublay Technique : large prosthesis in the space between the abdominal muscles and the peritoneum. III. Combined Fascial and Mesh Closure: posterior fascia is closed primarily, The anterior fascia is then bridged with a prosthesis IV. Sublay Technique :not suited for swiss- cheese hernia IV. Sublay Technique :not suited for swiss- cheese hernia

59. THANK YOU!!!

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62. References