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

2. 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

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

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

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

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

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

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

9. 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

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

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

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

13. 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

14. 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)

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

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

17. 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 ; 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)