VENTRAL HERNIA BY IBRAHIM GALAL PROFESSOR OF SURGERY
VENTRAL HERNIA BY IBRAHIM GALAL PROFESSOR OF SURGERY, CAIRO UNIVERSITY
GUIDELINES • European Hernia Society (EHS) HERNIA, 2014. • INTERNATIONAL ENDO HERNIA SOCIETY (IEHS), SURG ENDOSC, 2014. • THE SOCIETY OF AMERICAN GASTROINTESTINAL AND ENDOSCOPIC SURGEONS (SAGES) CONGRESS , 2014. • SAGES guidelines for laparoscopic ventral hernia repair (SAGES) SAGES Guidelines Committee, 2016.
DEFINITION • HERNIA : PROTRUSION OF VISCUS THROUGH A DEFECT IN THE WALL OF ITS CONTAINING CAVITY. • VENTRAL HERNIA : ANY HERNIA AFFECTING THE ABDOMINAL WALL (EXCLUDING THE GROIN)
CLASSIFICATION OF VENTRAL HERNIA 1 -PRIMARY: A- MIDLINE: -EPIGASTRIC -UMBILICAL B-LATERAL: -SPIGELIAN - LUMBAR 2 -SECONDARY (INCISIONAL): A- MIDLINE: -SUBXIPHOID -EPIGASTRIC -UMBILICAL -SUBUMBILICAL. -SUPRAPUBIC. B- LATERAL: -SUBCOSTAL -FLANK -ILIAC (PARASTOMAL) -LUMBAR MUYSOMS FE et al, CLASSIFICATION OF PRIMARY AND INCISIONAL ABDOMINAL WALL HERNIAS. HERNIA, 2009 AUG; 13(4): 407 -14
ETIOLOGY • ABDOMINAL HYPERTENTION: COPD, BPH, CONSTIPATION, ASCITIS, PRGNANCY, OBESITY, STERNEOUS ACTIVITY, TENSION REPAIR OF ABDOMINAL WALL. • PARIETAL WEAKNESS: INCISION, AGING, OBESITY, NUTRTIONAL, MESENCHYMAL DISORDER (MARFAN’S & EHLERS DANLOS SYNROMES )
PATHOLOGY 1 - SAC : PERITONIUM. 2 - DEFECT : ABDOMINAL WALL LAYERS.
COMPLEX VENTRAL HERNIA ETIOLOGY: • • TRAUMA. TUMOUR RESECTION. PREVIOUS MULTIPLE LAPAROTOMIES. INFECTION.
COMPLICATIONS • • POOR QUALITY OF LIFE. IRREDUCIBLITY. OBSTRUCTION. STRANGULATION. INCARCERATION (REDUCIBLE BY GENTLE TAXIS). INFLAMATION (AMYAND’S=APPENDIX). HYDROCELE.
CLINICAL PICTURE • • PAIN (SPORTMAN’S HERNIA). SWELLING. (INTERMITTENT). IO. INFLAMATION.
INVESTIGATIONS MULTIDETECTOR CT (MDCT) CAN SHOW: THE ANATOMY OF THE HERNIA SAC. THE CONTENTS OF THE SAC. COMPLICATIONS. CLEAR DETAILS OF THE ABDOMINAL WALL ALLOWING DEFECT TO BE IDENTIFIED ACCURATELY. • EXACT ABDOINAL DOMAIN : HV/AV RELATIVE VOLUME OF HERNIA/ABDOMINAL CAVITY. • •
HERNAI / ABDOINAL DOMAIN
LOSS OF ABDOINAL DOMAIN ↑ 25%
LOSS OF ABDOINAL DOMAIN
MANAGEMENT • • WACHFUL EXPECTANCY. TRUSS. TAXIS. SURGERY.
NEONATAL UH
TRUSS
SURGICAL APPROACH • OPEN. • LAPAROSCOPIC. • COMBINED (ASSISTED).
FEASIBILITY OF LAPAROSCOPIC REPAIR • • MEDIUM SIZE DEFECT (2 - 10 CM). FEASIBLE MESH OVERLAP BY 5 CM. RECURRENT. OBESE
CONTRAINDICATIONS TO LAPAROSCPIC REPAIR 1 -LOSS OF DOMAIN. 2 -LOSS OF COVER (SKIN LOSS, GRAFT). 3 -INFECTION /ACTIVE ENTERCUTANEOUS FISTULA. 4 -NEED FOR REMOVAL OF OLD MESH. 5 -LARGE DEFECT SIZE (↑ 10 cm). 6 -INCARCERATED HERNIA.
LAPAROSCPIC REPAIR • NO NEED FOR SAC EXCISION. ( ? HUGE) • NO NEED FOR DRAIN( ? ADHESIOLYSIS OR ENTEROTOMY) • NO NEED FOR HERNIORRAHPHY. (HOWEVER IF DONE: ↓SEROMA, ↓RECURRENCE)
PRINCIPLES OF SURGICAL TREATMENT OF VENTRAL HERNIA 1 - REDUCTION OF CONTENTS. 2 - REPAIR OF PARIETY. (SOMETIMES BOTH ARE DONE IN THE SAME TIME)
REDUCTION OF CONTENTS 1 - SPONTANEOUS. 2 - TAXIS. 3 - PNEUMOPERITONIUM/BOTOX. 4 - INTRA-ABDOMINAL EXPANDER. 5 - RESECTION. 6 - ADHESIOLYSIS. 7 - BOGOTA BAG. 8 - VACUUM ASSISTED CLOSURE (VAC THERAPY ). 9 - STAGED PROSTHETIC REDUCTION.
BOGOTA BAG
STAGED PROTHETIC REDUCTION N. M. POSIESLSKI ET AL: REPAIR OF MASSIVE VENTRAL HERNIAS WITH “QUILTED” MESH. HERNIA, JUNE, 2015, PP 465
VACUUM ASSISTED CLOSURE
VAC THERAPY 1 - MODE : A- FIRST 48 hs: CONTINUOUS B- REST OF TTT: INTERMITTENT (5 MIN ON /2 MIN OFF). 2 -TARGET PRESSURE: 125/175 mmhg. 3 -CHANGE DRESSING: EVERY 2/3 DAYS (OR MORE)
REPAIR OF PARIETY A- SMALL DEFECT ( ≤ 2 cm) : PRIMARY CLOSURE. B- MEDIUM DEFECT ( 2 -10 cm) : MESH HERNIOPLASTY (OPEN/IPOM). C- LARGE DEFECT ( ↑ 10 cm) : 1 - ELECTIVE: COMPONENT SEPARATION/MESH. 2 - URGENT: MESH BRIDGING/± SERIAL MESH EXCISION.
COMPONENT SEPARATION • ANTERIOR. • POSTERIOR.
ANTERIOR COMPONENT SEPARATION • RELEASE OF EXTERNAL OBLIQUE MUSCLE AT THE ANTERIOR AXILLARY LINE BILATERALLY (OPEN/ENDO). • DIVISION OF THE BOTH ANTERIOR RECTUS SHEATHS VERTICALLY INTO MEDIAL & LATERAL FLAPS. • TURN MEDIAL FLAPS TOWARDS MIDLINE AND JOIN THEM BY NONABSORBABLE SUTURES.
COMPONENT SEPARATION • ANTERIOR.
SUBCUTANEOUS DISSECTION. RELEASE OF EXT OBLIQUE. DIVISION OF ANT SHEATH.
POSTERIOR (LAPAROSCOPIC) COMPONENT SEPARATION • RELEASE OF TRANSVERSUS ABDOMINIS MUSCLE AT THE ANTERIOR AXILLARY LINE BILATERALLY. • DIVISION OF THE BOTH POSTERIOR RECTUS SHEATHS VERTICALLY INTO MEDIAL & LATERAL FLAPS. • TURN MEDIAL FLAPS TOWARDS MIDLINE AND JOIN THEM BY NONABSORBABLE SUTURES.
COMPONENT SEPARATION • POSTERIOR.
PARASTOMAL HERNIA
PARASTOMAL HERNIA • DRWABACKS OF STOMA RESITING: 1 - INCISIONAL HERNIA IN THE LAPAROTOMY WOUND. 2 - RECCURENCE OF OLD PARASTOMAL HERNIA. 3 - NEW SITE PARASTOMAL HERNIA • 40 % RECCURENCE.
LAPAROSCOPIC REPAIR OF PARASTOMAL HERNIA KEYHOLE REC: 27 % HANSSON, ET AL. , SURG ENDOSC. 2009 JULY
LAPAROSCOPIC REPAIR OF PARASTOMAL HERNIA KEYHOLE REC: 27 % SUGARBAKER REC: 16 % HANSSON, ET AL. , SURG ENDOSC. 2009 JULY
SUGARBAKER
MESH (PROSTHSIS) • • BRIDGE (STAGED PROSTHETIC REDUCTION). ONLAY (OVER THE MUSCLES). SUBLAY (SUBMUSCULAR/EXTRAPERITONEAL). IPOM (NON ADHESIVE MESH).
SUBCUT/ONLAY DEFECT BRIDGE SUBLAY EXTRAPERITONEAL INTRAPERITONEAL
MESH FIXATION • • GLUE : WEAK SUTURES: DIFFICULT TACKS : MESH MIGRATION/SHRINKAGE STALPES: NERVE ENTRAPMENT • BEST FIXATION: - SUTURES WITH TACKS - 1. 5 cm APART - DOUBLE CROWN.
POSTOPERATIVE COMPLICATIONS • SEROHEMATOMA. • PAIN. • RECURRENCE (TRUE& PSEUDO).
BOTOX • • 50 UNITS INTRAMUSCULAR BOTULINUM TOXIN A WAS DELIVERED PRE-INCISION INTO THE OBLIQUE MUSCLES AT EACH SIDE UNDER ULTRASOUND GUIDANCE THE MAXIMAL THICKNESS OF THE EXTERNAL OBLIQUE, INTERNAL OBLIQUE AND TRANSVERSUS ABDOMINUS MUSCLE COMPLEX AT THE LEVEL OF THE AORTIC BIFURCATION WAS MEASURED AND COMPARED 30 DAYS POSTOPERATIVELY, THE OBLIQUE THICKNESS WAS REDUCED BY 43%, 50% AND 110% DUE TO LENGTHENING CT SCAN AT 6 MONTHS, DEMONSTRATED THAT THE THICKNESS HAD RETURNED TO WITHIN 8% OF ITS PREOPERATIVE BASELINE. CONCLUSIONS: BOTULINUM TOXIN WAS EASILY ADMINISTERED UNDER ULTRASOUND GUIDANCE, AND APPEARED TO HAVE A MEASUREABLE EFFECT BY DAY 4
- Slides: 49