Management of Ventral Hernias hernia-js.pdf · Physical Exam – All vitals WNL ... GI tract...
Transcript of Management of Ventral Hernias hernia-js.pdf · Physical Exam – All vitals WNL ... GI tract...
Management of Ventral Hernias
Jason Sulkowski MD
www.downstatesurgery.org
Case • xx y F with epigastric hernia presented with pain over
hernia & NBNB emesis
• PMH: C-section
• Meds: None
• Allergies: NKDA
• Social: Denies toxic habits
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• Physical Exam – All vitals WNL – Abdomen: 4cm round, firm, nontender,
nonreducible hernia cephalad to umbilicus; otherwise soft, NT ND, C-section scar
• Labs:
– BMP: 135/3.9 94/28 19/0.8 <130 – Lactate: 1.8 – CBC: 19.5> 15.6/46.4 <284
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• Imaging – CT A/P: ventral hernia with partial small
bowel obstruction, pelvic free fluid
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OR Course • Midline incision over hernia • Dissection carried to hernia sac
– Sac was isolated, opened • Ischemic omentum and bowel within sac • Sac resected, edges of hernia defect freed from adhesions
– Defect size 2cm wide x 4cm long • Ischemic omentum resected • After ~15 min waiting, small bowel did not improve • Resection of 20cm mid-jejunum with primary anastomosis
– Side to side functional end to end • Fascia closed primarily with running loop PDS
– No mesh
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Post-Op Course • POD 1
– Extubated in PACU
• POD 2 – + Flatus – NGT, foley removed
• POD 3
– Diet started
• POD 4 – Discharged home
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Questions? www.downstatesurgery.org
Management of Ventral Hernias www.downstatesurgery.org
Ventral Hernias
• Incisional
• Umbilical
• Epigastric
• 150,000 ventral hernia repairs annually – No reduction despite increased MIS
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Incisional Hernias • 10-15% of all surgical incisions will
herniate
• 90% of incisional hernias are midline ex-laps
• Risk factors1:
– Surgical site infection • Superficial • Deep
– BMI >25kg/m2
– Stitch length
1Jensen KK et al., Surg Endosc. 2016; 30(10): 4469-79.
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Umbilical Hernias • Congenital weakness in abdominal
wall at site of umbilical vessels
• Increased intra-abdominal pressure can cause defect to worsen in adulthood
• Important to identify prior to any
abdominal incision so it can be incorporated and repaired
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Epigastric Hernias • Diastasis recti
– Weakness between R & L rectus muscles
– Can be visualized with contraction of rectus muscles (inclining and reclining)
• Not during valsalva
• Epigastric hernia is true defect
• Important to identify prior to any abdominal incision so it can be incorporated and repaired
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Diagnosis & Management
• Elective
• Urgent / Emergent
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Reducible Hernia
• History
• Physical Exam
• Imaging
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Reducible Hernia Repair Indications • Expanding hernia
• Loss of domain
• Cosmesis
• Thinning of tissue over hernia
• Patient request
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Incarcerated / Strangulated Hernia
• History
• Physical Exam
• Imaging
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Incarcerated / Strangulated Hernia Repair Indications
• All must be fixed urgently or emergently
• Stabilize, resuscitate patient first !
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Classification System for Ventral Hernias
• European Hernia Society
• Ventral Hernia Working Group
• Hernia Patient Wound (HPW) System
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European Hernia Society
Description SSO Rate Recurrence Rate
Stage 1 <10 cm; Clean wound 10% 10%
Stage 2 <10 cm; Contaminated 10-20 cm; Clean 20% 15%
Stage 3 >10 cm; Contaminated Any >20 cm 40% 25%
Sabiston Textbook of Surgery, 20th Ed.
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Ventral Hernia Working Group Description Recommendations
Grade 1 Low complication risk; No wound infection history Repair as per surgeon preference
Grade 2 Co-morbid conditions (e.g. smoker, obese, DM2, immunosuppressed)
Increased SSO risk; Potential advantage for biologic reinforcement
Grade 3 Prior wound infection; Stoma present; GI tract violation
Permanent synthetic repair not recommended; Potential advantage for biologic reinforcement
Grade 4 Infected mesh Septic dehiscence Biologic repair material should be used
Montgomery A. Hernia. 2013; 17: 3-11.
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Hernia Patient Wound (HPW) System
Petro CC & Novitsky YW. Hernia Surgery. 2016.
• Like TNM system for cancer
• Hernia – H1: <10 cm – H2: 10-20 cm – H3: >20 cm
• Patient
– P0: no comorbidities – P1: at least 1
• Wound
– W0: clean – W1: contaminated
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Prevention www.downstatesurgery.org
Bite Size • STITCH Trial
– “Small bites versus large bites for closure of abdominal midline incisions: a double-blind, multicentre, randomised controlled trial”
– SBVLBFCOAMI ?!
• Prospective, multicenter, double-blind RCT – Post-op follow-up clinician and patient blinded
• Included: >18 years, undergoing elective abdominal surgery via
midline wound
• Excluded: prior midline incision within 3 months, pregnant, involved in other study
Deerenberg EB et al., Lancet. 2015; 386: 1254-60.
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• Large bites group: N = 248 – 1cm bites every 1cm – PDS 1 Loop with 48mm needle
• Small bites group: N = 276 – 5mm bites every 5mm – PDS 2-0 with 31mm needle
• Technique:
– 2 sutures placed from either end of incision – Overlap in middle by 2cm – Tied separately
• Primary outcome: incisional hernia detected by clinical
exam OR imaging
Deerenberg EB et al., Lancet. 2015; 386: 1254-60.
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• Hernia recurrence at 1 year (p = 0.022): – Large bites: 21% – Small bites: 13%
• Weaknesses:
– Use of imaging to detect hernias likely increased rates in both groups
– Use of different stitches in each group
Deerenberg EB et al., Lancet. 2015; 386: 1254-60.
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Interrupted vs Continuous • INSECT Trial
– “Interrupted or continuous slowly absorbable sutures – Evaluation of abdominal closure techniques”
• Prospective, multicenter, RCT • Included: >18 years, undergoing elective abdominal
surgery via midline wound expected to be >15 cm
• Excluded: emergency procedure, recent chemoTx or radioTx
Seiler CM et al., Ann Surg. 2009; 249 (4): 576-82.
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• Interrupted Vicryl: N = 152 • Continuous Monoplus: N = 162 • Continuous PDS: N = 158
• Primary outcome: incisional hernia detected by
ultrasound
Seiler CM et al., Ann Surg. 2009; 249 (4): 576-82.
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• Hernia recurrence at 1 year (p = 0.087): – Interrupted Vicryl: 15.9% – Continuous Monoplus: 12.5% – Continuous PDS: 8.4%
• Conclusion:
– Trend towards improved outcomes with continuous closure technique
– Rates are still high and new techniques are needed
Seiler CM et al., Ann Surg. 2009; 249 (4): 576-82.
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Prophylactic Mesh – “Prevention of incisional hernias by prophylactic mesh-augmented
reinforcement of midline laparotomies for AAA treatment”
• Prospective, multicenter, RCT • Included: undergoing elective AAA repair via midline
incision
• Excluded: emergency procedure, prior incisional hernia repair or mesh placement
Muysoms FE et al., Ann Surg. 2016; 263 (4): 638-45.
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• Non-mesh: N = 58 – Fascia closed with continuous PDS suture
• Mesh: N = 56 – Ultrapro mesh (polypropylene) placed retromuscular – Fascia closed with continuous PDS suture
• Primary outcome: incisional hernia detected by
clinical exam OR imaging
Muysoms FE et al., Ann Surg. 2016; 263 (4): 638-45.
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• Hernia recurrence at 2 years (p < 0.0001): – Non-mesh: 28% – Mesh: 0%
• No adverse effects related to mesh placement
• Conclusion:
– Significant reduction in incisional hernias with mesh placement
– Dissemination of these techniques for all surgeons
Muysoms FE et al., Ann Surg. 2016; 263 (4): 638-45.
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Treatment Approaches www.downstatesurgery.org
Ventral Hernia Repair Approaches • Tension Repairs
– Primary tissue-to-tissue – Inlay mesh – Abdominal wall
reconstruction – Reconstruction plus mesh
• Tension-Free Repairs
– Sublay – Onlay
• Laparoscopic or Open
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Rives-Stoppa Repair
• Considered Gold Standard for midline ventral hernias
• Sublay mesh repair
• Principles:
– Separate posterior sheath from rectus muscle – Close peritoneum – Place mesh pre-peritoneal and retromuscular – Close linea alba over mesh – Mesh is isolated from peritoneum and
subcutaneous tissue
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Hernia Repair Battles
• Tissue (or Suture or Primary) vs Mesh Repair
• Laparoscopic vs Open Repair
• Which mesh is the best?
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Hernia Repair Battles
• Tissue (or Suture or Primary) vs Mesh Repair
• Laparoscopic vs Open Repair
• Which mesh is the best … for my patient?
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Tissue Repair vs Mesh - Incisional • Multicenter RCT
• Included: patients with incisional hernia <6 cm long
• Excluded: infection, multiple hernias
• Tissue repair: N = 97
– Polypropylene sutures 1 cm apart • Mesh repair: N = 84
– Polypropylene mesh, underlay with 2-4 cm overlap – Covered with peritoneum or Vicryl mesh
Luijendijk RW et al., N Engl J Med. 2000; 343: 392-8.
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• Primary outcome: hernia recurrence by exam OR ultrasound
• Hernia recurrence within 3 years (p = 0.005)
– Tissue repair: 46% – Mesh repair: 23%
• Risk factors for recurrence:
– Mesh repair: 0.4 (0.2, 0.8) – Infection: 4.3 (1.5, 12.6) – Previous surgery for AAA: 3.8 (1.7, 8.5)
Luijendijk RW et al., N Engl J Med. 2000; 343: 392-8.
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• Additional long term follow up: – Tissue repair: 75 months – Mesh repair: 81 months
• Hernia recurrence (p < 0.001)
– Tissue repair: 63% – Mesh repair: 32%
• Complications (mesh repair):
– Sinus tract from mesh: 5% – Enterocutaneous fistula: 3%
Burger JWA et al., Ann Surg. 2004; 240(4): 578-85.
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Tissue Repair vs Mesh – Umbilical/Epigastric
• Meta-analysis
• Included: 9 studies comparing elective suture and mesh repair of primary ventral hernias
• Combined totals: – Suture repair: N = 1145 – Mesh repair: N = 637
Nguyen MT et al., JAMA Surg. 2014; 149 (5): 415-21.
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• Pooled hernia recurrence rates (p < 0.001): – Non-mesh: 8.2% – Mesh: 2.7% – Odds ratio: 0.31 (0.18, 0.52)
• Multivariate analysis
– Recurrence associated with suture repair
– Seroma (3.8% vs 7.7%) and SSI (6.6% vs 7.3%) associated with mesh repair
Nguyen MT et al., JAMA Surg. 2014; 149 (5): 415-21.
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Mesh Repair – Incarcerated • Prospective cohort study
• 80 patients with incarcerated or strangulated ventral hernias repaired with onlay polypropylene mesh
• Bowel resection in 18 (22.5%) • Peri-operative mortality 2 (2.5%)
• Mean follow up: 50 months
Bessa SS et al., Hernia. 2013; 17 (1): 59-65.
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• Recurrence rate: 1.3%
• Complications: – SSI: 11.3% – Seroma: 6.3% – PNA: 5% – DVT: 1.3% – Mesh infection: 1.3%
• Use of mesh is safe for incarcerated hernias +/- bowel
resection
Bessa SS et al., Hernia. 2013; 17 (1): 59-65.
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Biosynthetic Mesh Repair – Contaminated
• COBRA Study – “Complex open bioabsorbable reconstruction of the abdominal wall.”
• Prospective cohort study
• Included: ventral hernia with clean-contaminated or contaminated wound, closed single piece of GORE BIO-A mesh
• Excluded: clean or dirty wounds, significant comorbidities
Rosen MJ et al., Ann Surg. 2015; Epub.
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• N = 104, 24 months follow up
• Recurrence: 17% – More likely with intraperitoneal mesh placement (40% vs 13%, p = 0.045)
• Wound infection: 18%
– Superficial: 9% – Deep incision: 10% – Organ space: 2%
• Other complications: – Fistula: 2% – Bowel obstruction: 2% – Wound dehiscence: 1%
Rosen MJ et al., Ann Surg. 2015; Epub.
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Summary: Tissue vs Mesh Repair • Mesh repair associated with lower recurrence than tissue repair
for: – Incisional hernias – Umbilical and epigastric hernias – Incarcerated hernias and contaminated fields
• Mesh repair associated with increased complications – Still relatively uncommon
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Laparoscopic Repair
• First described in 1992 – Now being used with increasing frequency
• Principles:
– Safe entry into abdomen – usually NOT the umbilicus – Ports placed lateral enough to allow 3-5 cm overlap of
mesh – Perform careful adhesiolysis and reduction of hernia – Measure defect size – Insert and attach the mesh
• Tacks ok if mesh will have tissue ingrowth • Sutures recommended if mesh will have minimal tissue ingrowth
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Open vs Laparoscopic Repair • Meta-analysis
• 12 prospective RCTs comparing open vs laparoscopic incisional hernia repairs
• Increase in bowel complications for laparoscopic repair – OR: 2.56 (1.15, 5.72)
Awaiz A et al., Hernia. 2015; 19 (3): 449-63.
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• Open and laparoscopic repairs similar for: – Operative time – Overall complications – Wound infections – Hematoma / seroma – Time to PO intake – Length of stay – Back to work – Recurrence rate
Awaiz A et al., Hernia. 2015; 19 (3): 449-63.
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Open vs Laparoscopic Repair • Cochrane Systematic Review
• 10 prospective RCTs comparing open vs laparoscopic ventral hernia repairs
• Increase in bowel complications for laparoscopic repair – OR: 2.33 (0.53, 10.35)
• Decrease in SSI for laparoscopic repair
– RR: 0.26 (0.15, 0.46)
Sauerland S et al., Cochrane Database Syst Rev. 2011; 16 (3).
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• Open and laparoscopic repairs similar for: – Recurrence rates
• Data too heterogeneous to make conclusions about:
– Operative time – Length of stay – Pain
Sauerland S et al., Cochrane Database Syst Rev. 2011; 16 (3).
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Abdominal Wall Reconstruction • More complex defects require more
complex repairs
• Many (many) different techniques
• Mesh still used in many cases – Overlay mesh to provide extra strength – Inlay mesh to bridge a gap in fascia edges
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Component Separation • First described by Ramirez et al. in 1990
• Technique:
– Create subcutaneous flap laterally – Relaxing incision 2 cm lateral to linea
semilunaris – Blunt dissection between external and
internal oblique muscles
Ramirez OM et al., Plast Reconstr Surg. 1990; 86 (3): 519-26.
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Transversus Abdominis Release • First described by Novitsky et al. in
2012
• Technique: – Incise posterior rectus sheath near midline – Dissect sheath away from rectus muscle – Junction of anterior and posterior sheath is
incised at linea semilunaris – Tranversalis fascia is dissected away from
transversus abdominis
Novitsky YW et al., Am J Surg. 2012; 204 (5): 709-16.
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Conclusions • Common
• All shapes and sizes
• Mesh repairs associated with lower recurrence – Safe to use for incarcerated / strangulated hernia with bowel resection – Safe to use for contaminated fields
• No definitive benefit to laparoscopic repairs
• Nearly as many types of repairs as types of hernias
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Conclusions • Adapt your repair technique to each unique hernia defect
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Questions!
Risk factors for development of an incisional hernia include all of the following EXCEPT: • A. Smoking • B. BMI <30 • C. Malnutrition • D. Steroids • E. Wound infection
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Questions!
Risk factors for development of an incisional hernia include all of the following EXCEPT: • A. Smoking • B. BMI <30 • C. Malnutrition • D. Steroids • E. Wound infection
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Questions!
Which of the following is NOT true with regard to incisional ventral hernias? • A. Primary repairs are associated with 30-50% recurrence. • B. The incidence of incisional hernias after laparotomy is ~10%. • C. All types of mesh can be safely placed in the intra-abdominal
cavity. • D. Prosthetic mesh repairs have reduced the recurrence to <10%. • E. Comorbidities such as DM2, HTN, and obesity, and common in
patients with incisional hernias.
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Questions!
Which of the following is NOT true with regard to incisional ventral hernias? • A. Primary repairs are associated with 30-50% recurrence. • B. The incidence of incisional hernias after laparotomy is ~10%. • C. All types of mesh can be safely placed in the intra-abdominal
cavity. • D. Prosthetic mesh repairs have reduced the recurrence to <10%. • E. Comorbidities such as DM2, HTN, and obesity, and common in
patients with incisional hernias.
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