Ernie Della Parete Addominale
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Transcript of Ernie Della Parete Addominale
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ERNIE E LAPAROCELIERNIE E LAPAROCELI
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ERNIE ADDOMINALIERNIE ADDOMINALI
DEFINIZIONE: fuoriuscita di un DEFINIZIONE: fuoriuscita di un viscere o di una parte di esso dalla viscere o di una parte di esso dalla cavità in cui è normalmente cavità in cui è normalmente contenutocontenuto
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TIPI DI ERNIE PER SEDETIPI DI ERNIE PER SEDE
InguinaleInguinale CruraleCrurale OmbelicaleOmbelicale EpigastricaEpigastrica SpigelioSpigelio OtturatoriaOtturatoria IschiaticaIschiatica LombareLombare PerinealePerineale LaparoceleLaparocele
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ERNIE ADDOMINALIERNIE ADDOMINALI
CONGENITE: arresto dello sviluppo CONGENITE: arresto dello sviluppo delladella
pareteparete
ACQUISITE: da debolezza e da sforzo ACQUISITE: da debolezza e da sforzo
Predisponente DETERMINANTE
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ERNIE ADDOMINALIERNIE ADDOMINALI
CAUSE PREDISPONENTICAUSE PREDISPONENTI
- malformazioni congenite- malformazioni congenite
- gravidanza- gravidanza
- BPCO- BPCO
- stipsi cronica- stipsi cronica
- ascite- ascite
- calo ponderale- calo ponderale
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ERNIE ADDOMINALIERNIE ADDOMINALI
CAUSE DETERMINANTICAUSE DETERMINANTI
- sforzi- sforzi
- traumi- traumi
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ERNIE ADDOMINALIERNIE ADDOMINALI
ELEMENTI COSTITUTIVIELEMENTI COSTITUTIVI
- porta erniaria- porta erniaria
- sacco erniario- sacco erniario
- viscere erniato- viscere erniato
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ERNIE ADDOMINALIERNIE ADDOMINALI
CONTENUTOCONTENUTO
- epiploon- epiploon
- intestino tenue- intestino tenue
- colon- colon
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SEMEIOTICA FISICASEMEIOTICA FISICAISPEZIONE ISPEZIONE
SedeSede FormaForma DimensioneDimensione EspansibilitàEspansibilità CuteCute
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SEMEIOTICA FISICASEMEIOTICA FISICAPALPAZIONEPALPAZIONE
SuperficieSuperficie MarginiMargini ConsistenzaConsistenza DoloreDolore RiducibilitàRiducibilità EspansibilitàEspansibilità TermotattoTermotatto
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SEMEIOTICA FISICASEMEIOTICA FISICAPERCUSSIONEPERCUSSIONE
Suono timpanicoSuono timpanico Suono ottusoSuono ottuso
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SEMEIOTICA FISICASEMEIOTICA FISICAASCOLTAZIONEASCOLTAZIONE
peristalsiperistalsi
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SEMEIOTICA STRUMENTALESEMEIOTICA STRUMENTALE
EcografiaEcografia T.C.T.C.
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CLINICACLINICA
Punta d’erniaPunta d’ernia Ernia interstizialeErnia interstiziale Ernia completaErnia completa Ernia incarcerataErnia incarcerata Ernia intasataErnia intasata Ernia strozzataErnia strozzata
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICO
ERNIA INGUINALEERNIA INGUINALE
BASSINIBASSINI SHOULDICESHOULDICE PROTESIPROTESI LAPAROSCOPIALAPAROSCOPIA
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICO
ERNIA INGUINALEERNIA INGUINALE
BASSINIBASSINI
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICO
ERNIA INGUINALEERNIA INGUINALE
SHOULDICESHOULDICE
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICO
ERNIA INGUINALEERNIA INGUINALE
PROTESIPROTESI
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICO
ERNIA INGUINALEERNIA INGUINALE
LAPAROSCOPIALAPAROSCOPIA
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA CRURALEERNIA CRURALE
BASSINIBASSINI
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INTERVENTO CHIRURGICOINTERVENTO CHIRURGICOERNIA CRURALEERNIA CRURALE
PROTESIPROTESI
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INTERVENTO CHIRURGICOINTERVENTO CHIRURGICOERNIA OMBELICALEERNIA OMBELICALE
Plastica della paretePlastica della parete ProtesiProtesi
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA EPIGASTRICAERNIA EPIGASTRICA
PLASTICA DELLA PARETEPLASTICA DELLA PARETE PROTESIPROTESI
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA DI SPIGELIOERNIA DI SPIGELIO
Plastica della paretePlastica della parete ProtesiProtesi
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA LOMBAREERNIA LOMBARE
Plastica della paretePlastica della parete ProtesiProtesi
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA OTTURATORIAERNIA OTTURATORIA
Accesso addominaleAccesso addominale Accesso properitonealeAccesso properitoneale Accesso otturatorioAccesso otturatorio Accesso laparoscopicoAccesso laparoscopico
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA ISCHIATICAERNIA ISCHIATICA
Accesso laparotomicoAccesso laparotomico Accesso trans-gluteoAccesso trans-gluteo
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOERNIA PERINEALEERNIA PERINEALE
Accesso laparotomicoAccesso laparotomico Accesso diretto perinealeAccesso diretto perineale
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TRATTAMENTO CHIRURGICOTRATTAMENTO CHIRURGICOLAPAROCELELAPAROCELE
Plastica diretta della paretePlastica diretta della parete Plastica con protesiPlastica con protesi Plastica laparoscopicaPlastica laparoscopica
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COMPLICANZE
• Sistemiche
• Locali: Intra-addominali
• Parietali
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COMPLICANZE SISTEMICHE• Respiratorie
• Trombo-emboliche
• Cardiache
• Vascolari
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COMPLICANZE RESPIRATORIECAUSE
• Fattori pre-esistenti: obesità; tabagismo; BPCO; soggetto apatico.
• Brusco aumento pressione endo-addominale con risalita del diaframma.
• Dolore della ferita con respiro “economico” per fenomeni antalgici.
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PROFILASSI
• Correzione fattori di rischio pre-esistenti: sospensione fumo; dimagramento, ecc.
• FKT respiratoria.
• Pneumo-Peritoneo Progressivo sec. Goni Moreno.
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COMPLICANZE LOCALI• Incidenza 20% (range 5-44%)
• INTRA-ADDOMINALI: dovute a lesioni viscerali intra-operatorie e alle aderenze fra protesi e visceri
• PARIETALI
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COMPLICANZE
• L’insorgenza e l’incidenza di complicanze è correlabile a 2 fattori principali:
• Tipo di protesi utilizzata.
• Sede di impianto della protesi.
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A. COMPLICANZE INTRA-ADDOMINALI
• Perforazione di visceri (ileo, vescica)• Lesione di organi parenchimatosi (fegato, milza)• Ritardo di canalizzazione.• Occlusione intestinale.
• Penetrazione protesi in visceri cavi.• Fistole entero-cutanee.
• Le ultime sono complicanze di solito tardive
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COMPLICANZE INTRA-ADDOMINALI
• Sono gravi perché il loro mancato riconoscimento e trattamento mette in pericolo la vita del paziente.
• La perforazione dell’ileo e l’occlusione intestinale richiedono un reintervento. In chirurgia open le perforazioni sono riconosciute più facilmente.
• Hanno una discreta incidenza in laparoscopia (4% = 12 casi in 3 casistiche – Ben-Haim 2002; Parker 2002; Berger 2002- su un totale di 300 interventi).
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B. COMPLICANZE PARIETALI
• Sieromi.
• Ematomi.
• Infezioni.
• Lesioni ischemico-necrotiche della cute
• Eviscerazione
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1. SIEROMA
• Incidenza 7% (range 4-15%).
• Dipende dall’uso di drenaggi, dalla sede di impianto della protesi, dal tipo di protesi (classificazione di Amid).
• Può favorire l’insorgenza di infezione.
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SIEROMADrenaggi
• Secondo White (1998) (University of Nebraska) “the use of drains does not reduce the incidence of these complications”, intendendo sieromi ed ematomi, in quanto il sieroma compare quando il drenaggio è stato tolto e l’ematoma si forma quando l’emorragia è cospicua.
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SIEROMA: sede di impianto
• Sovrafasciale.
• Intraperitoneale laparoscopica: mancato trattamento del sacco; aggravato dall’uso di protesi microporose.
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SIEROMA:tipo di protesi
• Classificazione di Amid: le protesi macroporose favoriscono il drenaggio delle secrezioni
• Col PTFE l’incidenza di sieroma è 14%.
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CLASSIFICAZIONE DI AMID
TIPO I°: protesi macroporose con pori > 100 micron : Marlex, Trelex,Prolene, Atrium.
TIPO II°: protesi totalmente microporose con pori < 10 micron : ePTFE
TIPO III°: protesi macroporose con componenti multifilamentose o microporose: Mersilene, Mycromesh; Surgipro, Teflon.
TIPO IV°: pori < 1 micron : Sylastic
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DUALMESH II° TIPO
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2. EMATOMA
• Incidenza 3 – 8%
• Sede retromuscolo-preperitoneale.• Grandi laparoceli
• Può esser favorito da terapie anticoagulanti o antiaggreganti.
• Può richiedere reintervento per toeletta chirurgica ed emostasi
• Può favorire l’insorgenza di infezione.
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3. INFEZIONE
• Distinguere fra superficiali e profonde e tra precoci e tardive.
• In caso di impianto protesico secondo C.D.C. di Atlanta sono “precoci” quelle insorte entro 12 mesi dall’intervento, mentre senza protesi entro 30 gg.
• Incidenza: superficiali 5-6%; profonde 0.75% (in una revisione della letteratura del 1983 le profonde erano 6%)
• Fattori di rischio• Prevenzione
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Jean Rives. 1985
Les infections postopératoires ne sont pas l’effect d’une improbable intolérance , encore moins d’une mystérieuse fatalité. Elles sont le résultat d’une contamination locale.
Les parois peuvent receler des foyers d’inféction parfois aprés plusieurs années.
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INFEZIONE:fattori di rischio
• Protesi microporose.
• Fili di sutura intrecciati non riassorbibili
• Dimensioni della protesi: più è grande, maggiore è il rischio di infezione (ma minore quello di recidiva)
• Sede superficiale.
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Fattori generali che influenzano il tasso di infezione
• Stato del paziente: età, stato nutrizionale; malattie associate
• Preparazione : tricotomia, preparazione intestinale.
• Drenaggi: discussa come fattore. Esperienza del chirurgo e durata dell’intervento.
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INFEZIONE:prevenzione
• Protesi totalmente macroporose• Fili di sutura monofilamento• Profilassi antibiotica• Non associare interventi settici.• Discusso l’uso di protesi in campo clean-
contaminated, dove pare che con protesi macroporose l’incidenza di infezioni non sia superiore alla norma (Kelly-Behrman, Am Surg 2002,68;528)
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INFEZIONI INFEZIONI IN CHIRURGIA PROTESICAIN CHIRURGIA PROTESICA
….the virulence of Staph. pyogenesStaph. pyogenes for man is enhanced ten-thousand-foldten-thousand-fold by the presence of a
foreign body reaction to sutures….
(Elek,1956) Frequenza isolamenti
Staffi lococchi Coag – (sp. epidermidis)
Staffi lococco Coag + (sp. aureus)
Streptococchi
Pseudomonas aeruginosa
Proteus mirabilis
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INFEZIONI in CHIRURGIA PROTESICAINFEZIONI in CHIRURGIA PROTESICA
….per lo Staph. epidermidis,Staph. epidermidis, abituale costituente della flora cutanea …,considerato per decenni il prototipo
dei batteri non patogeni, a tutt’oggi non non sono identificabili altri modelli di malattia eccetto le infez. eccetto le infez.
da corpo estraneoda corpo estraneo…. (Concia,1998)
Antibiotici,Antibiotici,
Sist. Sist. immunitarioimmunitario
NutrientNutrientii
SlimeSlime
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“The use of prosthetic material does not increase the risk of infection, but makes it more difficult to
treat” R. Stoppa, 1998
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It is erroneous to assume that an infected mesh graft must be removed early to achieve wound healing.In most cases persistent infection is related to the presence of multi- filamentous suture, not monofilament mesh.It is important a high degree of patience by the surgeon, the patient and the family.Every problem should be clarified.
A. GILBERT 1997
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FASCITE NECROTIZZANTE
• Infezione da anaerobi gram - che richiede anche O2 terapia iperbarica, oltre a uno sbrigliamento chirurgico.
• Alta mortalità.
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4. LESIONI NECROTICO-ISCHEMICHE CUTANEE
• 1% degli operati.
• E’ l’effetto di vasti scollamenti.
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5. EVISCERAZIONE
• Dopo plastica o raffia: 0.5%
• Dopo protesi: 0.1%
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Complicanze particolari delle riparazioni laparoscopiche
• Conversione in open: Aura 1.2%
• Infezione del sito del trocar.
• Ernia sul sito del trocar 1,6% (Berger 4/150 casi; Renier: 1/135; Aura 1/86). Necessita reintervento.
• Dolore sul sito del trocar (Parker: 2/50 casi; Renier: 6/135 da tacker).
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Goodney et al. Arch Surg 2002,137:1161
• Metanalisi di studi che confrontano riparazioni open e laparoscopiche.
• Conclusioni: la tecnica laparoscopica offre minore incidenza di complicanze e più breve durata ricovero della tecnica open.
• Sono necessari ulteriori studi con follow-up più lungo per valutare le recidive.
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MORTALITA’ OPEN: 1%
• Romeo 1992: 0/160 (Rives e IPP, ePTFE)• Califano 1992: 0/98 (Rives)• Adloff 1987: 2/130 (IPP) (IMA e s.di Mendelsohn)• Arnaud 2000: 2/250 (IPP, dacron) (??)• Chevrel 1997: 0/236 (Onlay)• Mathonnet 1998: 2/172 (Rives 0/99; IPP 2/73) (??)• Rives 1985: 8/226 (Rives) (insuff. respiratoria)• Stoppa 1982: 4/342• Baulieux 1999: 0/192 (IPP, dacron)• Utrera 1999: 1/84 (IPP, ePTFE) (fascite necrotizzante)
• 19 / 1890 = 1%• IPP = IntraPeritoneal Prosthesis
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MORTALITA’ LAPAROSCOPIA
• Ben-Haim 2002; Renier 1999; Parker 2002; Berger 2002;
Heniford 2000; Aura 2002: 2/928 = 0.2%
• (embolia polm., IMA)
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MORTALITA’
• Secondo EMC la mortalità globale è del 1,2-1,5 %.
• La causa più frequente è l’insufficienza respiratoria intrattabile, insorta molto spesso dopo un intervento in urgenza.