A presentation of different abdominal Hernias.pptx

Hernia

1. Hernias Nabin Paudyal

2. Introduction Abdominal core: circumferential soft tissues of the diaphragm superiorly, pelvic floor inferiorly, abdominal wall and flank anterolaterally excluding abdominopelvic viscera Hernia management is an integral component of maintaining abdominal core health Hernia  Latin word Rupture Defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls Occurs at sites at which the aponeurosis and fascia are not covered by striated muscle.

3. Neck  innermost aponeurotic layer Sac Lined by peritoneum No relationship between area of the defect and size of the sac

4. Sequalae Reducible  Irreducible/ incarcerated Strangulation Adhesion between contents of the hernia and peritoneal lining of the sac can provide a tethering point that traps the hernia contents and predisposes to intestinal obstruction and strangulation. In Richter hernia  Small portion of the antimesenteric wall is trapped within the hernia it is an example of hernia in which strangulation can occur without presence of intestinal obstruction.

5. External hernia  Protrudes through all layers of abdominal wall Internal hernia Protrusion through a defect in the peritoneal cavity Interparietal hernia Hernial sac is contained within musculoaponeurotic layer of abdominal wall

6. P rinciple of hernia repair 6

7. Inguinal hernias

8. Inguinal hernia Direct and indirect Pantaloon  Both component present Incidence 5% of population develop abdominal wall hernia 75% of all abdominal wall hernia are inguinal 2/3 rd  Indirect hernia (MC hernia) Risk percentage Men: Women  25:1 In men  Indirect: Direct hernia 2:1 In women Indirect hernia is the MC type of hernia in women Femoral and umbilical hernia : female to male ratio  10:1 (Femoral); 2:1 (umbilical) 10% of women and 50% of men who have femoral hernia will develop inguinal hernia

9. Strangulation occurs in only 1-3% of groin hernias Most strangulated hernias are indirect inguinal hernias Femoral hernias have highest rate of strangulation (15-20%) of all hernias Presence of arterial aneurysm increases the risk of inguinal hernia. Hence all femoral hernias are repaired at the time of discovery.

10. Boundary of inguinal canal

11. Boundary of deep inguinal ring

12. Contents of spermatic cord Cremasteric muscle Testicular artery Accompanying veins Genital branch of genitofemoral N Vas deferens Cremasteric vessels Lymphatics Processus vaginalis

13. Iliopubic tract Most important structure in hernia repair Lateral to internal inguinal ring and along the portion of iliopubic tract staples and tacks are not applied because following nerves are located inferior to iliopubic tract Femoral Lateral femoral cutaneous Genitofemoral nerves

14. Preperitoneal space Nerves in preperitoneal space  Lateral femoral cutaneous N. (L2-L3), genitofemoral N (L2) A and V in preperitoneal space  Deep circumflex iliac A and V During lap hernia repair, one must dissect above iliopubic tract to avoid injury to these vessels. Vas deferens Courses caudal to cephalic direction and medial to lateral to join spermatic cord at deep inguinal ring

15. Diagnosis of hernia

16. Diagnosis Bulge in the groin Pain or vague discomfort in the region; 1/3 rd symptomless Extremely painful hernia  strangulation or incarceration Paresthesia related to compression or irritation of the inguinal nerves Examination of hernia Inspection Palpation Look for asymmetry and bulge Cough/ positive Valsalva Fingertip placement at the site of hernia N.B. distinction of indirect and direct hernia is not critical because repair is approached in the same way regardless of the type of hernia

17. Classification of hernia European Hernia Society classification

18. Nyhus classification How does inguinal canal maintain its integrity? Obliquity of canal  Flap valve Roof to floor approximation of IOM  Shutter valve Cremasteric muscle contraction causes plugging of superficial inguinal ring Ball valve V-shaped superficial inguinal ring preserves integrity Slit valve Hormones.

19. Management Nonoperative treatment Strategy of watchful waiting is safe for older patients with asymptomatic or minimally symptomatic inguinal hernias When operation is done, operative risks and complication risks are no different from patients undergoing operative repair. Adopted only for men. In women, if femoral hernia  Operative intervention In patients with non operative hernia repair Use of truss is recommended ; spring truss is recommended to be used. 30% of patients with truss report symptom control

20. Operative repair of inguinal hernia Anterior repair Most common operative approach TENSION FREE repair is now standard N.B. When an indirect hernia is present, the hernial sac is located deep to the cremaster muscle and anterior and superior to the spermatic cord structures Sac is dissected up to level of internal inguinal ring Sac can be: Opened and examined for contents Mobilized and placed into peritoneal cavity Ligated at the base of the sac Mesh prosthesis placed. Tissue repair Cases in which mesh prosthesis repair is contraindicated, we do tissue repair Used in strangulated hernia repair as mesh fixation is not done in such cases Options for tissue repair include  Iliopubic tract repair, Shouldice, Bassini, McVay repair, Darn repair, Halsted repair. [@MB-DISH] Laparoscopic and Preperitoneal repair TAPP, TEP, e-TEP.

21. Tissue repair Tissue repair has high rate of recurrence. Iliopubic tract repair Approximates transversus abdominis aponeurotic arch to iliopubic tract with interrupted sutures Repair begins at the pubic tubercle and extends laterally past the internal inguinal ring.

22. Shouldice repair Multilayer imbricated repair of the posterior wall of the inguinal canal with continuous running suture Initial suture layer  transversus abdominis aponeurotic arch to iliopubic tract (T--- IT ) Second layer  Internal oblique and transversus abdominis and aponeurosis are sutured to inguinal ligament (T---IL) HAS VERY LOW RATE OF RECURRENCE. Bassini repair Transversus abdominis and internal oblique aponeurosis or conjoint to the inguinal ligament Approach to non anatomic hernia repair McVay repair (Cooper ligament repair) Used for Direct hernia Large indirect hernia Recurrent hernia Femoral hernia Tr ansversus abdominis aponeurosis is approximated to Co oper ligament and iliopubic tract using interrupted suture (@ T—CI) Relaxing incision is given For femoral hernias

23. Shouldice repair

24. McVay repair

25. Bassini repair [Non-anatomic repair]

26. Tension-free anterior inguinal hernia repair Dominant method of hernia repair now Lichtenstein tension free mesh repair method Various modifications available Original Lichtenstein approach Plug and patch technique (of Gilbert) Sandwich technique Certain highlights of original Lichtenstein approach Fixation of the mesh to the pubic tubercle itself should be avoided, but to the shelving edge of the inguinal ligament Overlapping of the mesh should be by at least 15 mm

27. Plug and patch repair of (Gilbert) Cone-shaped plug of polypropylene mesh is inserted into the internal inguinal ring like an upside-down umbrella. Occlusion of the hernial site occurs (plug) Overlying mesh is placed (patch)

28. Sandwich technique for repair Involves use of bilayered device with three polypropylene components First layer underlay patch  Posterior repair similar to laparoscopic approach Connector similar to plug Third layer Onlay patch that covers the posterior inguinal floor. Stoppa-Rives repair Sub umbilical midline incision to place large prosthetic mesh into preperitoneal space Blunt dissection is used to create a space extra peritoneally from prevesical space to lateral pelvic brim Advantage in distributing abdominal pressure across a broad area to retain mesh in proper location Used for large, recurrent or bilateral hernias

29. Some important repair techniques

30. Laparoscopic hernia repair

31. Laparoscopic repair This approach provides mechanical advantage of placing a large mesh behind defect, covering myopectineal orifice and using natural forces to disperse intraabdominal pressure over larger area to support mesh in place 0.3% risk of vascular/ visceral injury Techniques Totally extraperitoneal approach (TEP) Transabdominal preperitoneal approach (TAPP) Extended TEP (e-TEP)

32. Myo pectineal orifice of Fruchaud Located along the inferomedial aspect of anterior abdominal wall Encompasses deep inguinal ring, inguinal triangle, portal inferior to inguinal ligament that transmits femoral neurovascular structures Inguinal ligament travels diagonally through the MPO dividing into 2 parts. Content: Round ligament (females) Spermatic cord (males) Surgical importance MPO is a common site of herniation

33. TEP approach Dissection begins in preperitoneal space Balloon dissector used Working space is more limited and there is a possibility of peritoneal injury If there is tear in peritoneum during TEP approach, there is conversion to TAPP approach. Hence knowledge of transabdominal technique is essential in performing lap hernia repair. Steps Infraumbilical incision Anterior rectus sheath incised Ipsilateral rectus abdominis retracted laterally Retro-rectus space created Dissecting balloon inserted deep to posterior rectus sheath, advanced to pubic symphysis and inflated Space is insufflated and additional trocars placed The inferior epigastric vessels are identified that serve as a landmark. Nerves that can be damaged  Femoral branch of genitofemoral N, LFCN of thigh

34. TAPP approach Infraumbilical incision given to access peritoneal cavity directly Two 5-mm ports placed lateral to inferior epigastric vessels at level of umbilicus Peritoneal flap created extending from median umbilical fold to ASIS Rest steps as per TEP Hernia reduction Small hernias  reduces itself Large sac is divided with cautery, near internal inguinal ring leaving distal sac in situ, proximal peritoneal sac is closed with loop ligature/ clips. Mesh deployment and fixation 12 cm X 14 cm polypropylene mesh used Covers direct, indirect, femoral

35. Measurements for placing polypropylene mesh Dissect peritoneum 4 cm off cord structures Fix mesh at least 2 cm above the hernia defect Structures in which the mesh is fixed Medially  Cooper ligament Anteriorly Posterior of the rectus abdominis muscle and transversus abdominis Laterally Iliopubic tract Inferiorly is nerve  (within the triangle of doom) hence inferior tacker is not used

36. Complications of inguinal hernia repair Recurrence No significant differences amongst various techniques for repair Risk of death is related to the comorbid conditions of the patient Type of anesthesia doesn’t affect the recurrence rate of hernia Recurrence rate of hernia 1.7-10%. Tension free repair have low hernia recurrence rate than tissue repair Open and laparoscopic have similar rate of hernia recurrence Danish Hernia data base  Lichtenstein mesh repair hernia recurrence 25% Shouldice repair has highest rate of recurrence Approximately 50% of recurrence occurs within 3 years after primary repair No difference in recurrence between TAPP and TEP repair.

37. Femoral hernia

38. Boundary of femoral canal Anterior: Inguinal ligament Posterior: Pectineal ligament Lateral: Thin septum separating it from femoral vein. Medial: Gimbernat’s ligament (lacunar ligament)

39. Boundary of femoral hernia Superiorly  Iliopubic tract Inferiorly Cooper ligament Laterally  Femoral vein Medially Junction of iliopubic tract and Cooper ligament (arcuate ligament)

40. 50% of men with femoral hernia will have associated direct inguinal hernia Repairing the femoral hernia Can be cooper ligament repair/ preperitoneal approach/ laparoscopic approach. Dissection and repair of hernial sac Obliteration of defect in femoral canal 2 ways to approximate Iliopubic tract and Cooper ligament approximation Prosthetic mesh placement Mesh is not used in cases with strangulation All femoral hernias should be repaired. Recurrence 2% after primary repair 10% after re-repair 3 types of repair is done in femoral hernia Mc Evedy repair (High-inguinal) Lothessian repair (Inguinal) Lockwood repair (Low-inguinal) 3 types of femoral hernia Narath hernia  lies beneath femoral vessels Languier’s hernia Arises from gap in lacunar ligament (usually strangulated) Cloquet hernia underneath the fascia of pectineus muscle

41. Lockwood repair Low or infra-inguinal approach Incision given directly over swelling Sac is carefully dissected out Sac ligated at neck, excised and hernia is repaired Inguinal ligament sutured to cooper’s ligament – obliterates femoral ring Indicated for uncomplicated hernia

42. Lotheissein Trans inguinal approach Incision 2cm above inguinal ligament; inguinal canal is opened Hernial sac visualized Excision of sac Preferred when there is strangulated femoral hernia

43. Mc Evedy High inguinal approach Skin incision given 3 cm above pubic tubercle running laterally Preferred in emergency setting when strangulation is suspected allowing better access to and visualization of bowel for possible resection [ Video demonstration of Mc Evedy incision and operation ]

44. Midline Abdominal Extraperitoneal Femoral Hernioplasty (Henry Procedure) Procedure of choice now for femoral hernia Doesn’t damage the transversalis fascial floor

45. Some caveats of hernia Recurrent hernias require placement of mesh for successful repair Recurrent hernia after anterior repair require either laparoscopic repair/ posterior mesh placement For bilateral inguinal hernia  Giant prosthetic repair (Stoppa repair) or laparoscopic repair for simultaneous repair of both hernias

46. Complications of hernia repair

47. Complications of hernia repair Increased scarring and disturbed anatomy with hernia recurrence can result in an inability to identify important structures at operation. Hence different approach for recurrent hernias is recommended. 10% overall complication of hernia A. Surgical site infection 1-2% of open repair No recommendation for use of antimicrobials prior surgery Patients with ASA 3 status  cefazolin 2 to 3 g IV 30-60 minutes before the incision In allergic patients Clindamycin 900 mg IV. Superficial SSI  open the incision, local wound care, secondary intention healing Deep SSI  Removal of the mesh Treat any skin condition prior inguinal repair (if exists)

48. B. Nerve injuries and Chronic pain syndromes Most commonly affected nerves in open repair  ilioinguinal N, genital branch of GF N, iliohypogastric N. Most commonly affected nerves in lap repair  LFC nerve, GF nerve. Neuralgias that occur may be: Transient: Self-limited, sensory involvement Persistent: pain and hyperesthesia, exacerbated by hyperextension of the hip and relieved by flexion of the thigh. Chronic postherniorrhaphy pain : Pain persisting more than 3 months after operation Strategies of routine nerve division have not been associated with reduction in chronic groin pain. Division of ilioinguinal N is associated with significantly more sensory disturbances. Management: Identify and preserve all 3 N Avoid direct fixation to Pubic tubercle Minimal disruption of cremasteric muscle Use of interrupted suture fixation superiomedially

49. Management of residual neuralgia NSAIDS Analgesics Local anesthetics Surgical approach to groin pain Local intervention  Mesh excision, Tack excision, Mesh debulking Nerve-related intervention Neurectomy

50. c. Ischemic orchitis and testicular atrophy Occurs usually from thrombosis of small veins of pampiniform plexus within spermatic cord Results in venous congestion  Testicular swelling 2-5 days after surgery testicular atrophy Caused by unnecessary dissection within spermatic cord Especially while dissection of distal portion of large hernial sac Hence for large hernias, posterior approach is preferred Ischemic orchitis may lead to testicular atrophy Incidence of ischemic orchitis increased by factor of 3-4 with each subsequent hernia repair. Hence ischemic orchitis occurs while doing recurrent hernia repair Management  NSAIDS and anti-inflammatory

51. d. Injury to vas deferens and viscera Unusual Usually in management of sliding hernia  when there is failure to recognize presence of intraabdominal viscera in hernia sac e. Inguinal hernia recurrence Caused by technical factors like excessive tension during hernia repair missed hernias failure to include an adequate musculoaponeurotic margin improper mesh size improper mesh placement failure to close patulous hernial ring intra abdominal pressure chronic cough deep infections poor collagen formation in wound Direct hernias recur more Femoral hernias may be present in cases with Inguinal hernia recurrence. Must be investigated.

52. Management of recurrent inguinal hernias Use prosthetic mesh Choose different OT approach Avoid dissection through scar tissue Recurrences can be best managed by placing second prosthesis through different approach Rate of recurrence is similar in both laparoscopic and open approach Re-recurrence rates 4-5% in first 24 months 7.5% at 5 years

53. Ventral hernias

54. Definition and incidence A ventral hernia is protrusion through the anterior abdominal wall May be spontaneous or acquired Acquired hernias  Incisional hernias Diastasis recti stretch in Linea alba resulting in bulge at the medial margin of rectus muscle Unless significantly symptomatic Don’t repair Incisional hernia  15% Umbilical hernia and epigastric hernia 10% Incisional hernias are twice common in ladies Causes Obesity Old age Male Sleep apnea Emphysema Prostatism Wound infection

55. Incidence of ventral hernia and surgery incision types Midline  10.5% Transverse 7.5% Paramedian 2.5% Ventral hernias are to be repaired when discovered. Classification of ventral hernia Umbilical hernia Epigastric hernia Incisional hernia

56. Umbilical hernia

57. Umbilical hernias in infants are congenital. Most spontaneously close by 2 years Persistent hernias after 5 years of age require surgery Umbilical hernias in adults are acquired More in women Indications for repair Large hernia Incarceration Uncontrollable ascites Thinning of overlying skin Mayo’s repair  vest over pants Involves 2-layered imbrication of superior and inferior fascial edges Mayo’s repair has recurrence of 30% Not done nowadays Defect size < 3cm Primary repair >3 cm Mesh repair

58. Umbilicus: adult vs neonate

59. Epigastric hernia

60. 3-5% of hernias 2-3 times more common in men Usually in location between xiphoid process and umbilicus (5 to 6 cm within) Feature is to produce pain out of proportion Pain is caused by incarceration of preperitoneal fat Repair involves: Excision of preperitoneal tissue Simple closure of fascial defect Epigastric hernias are repaired anteriorly

61. Incisional hernia

62. Most challenging and difficult Occurs as a result of excessive tension and inadequate healing of previous incisions Hernias enlarge over time, cause pain, bowel obstruction, incarceration and strangulation Risk factors Obesity Advanced age Malnutrition Ascites Pregnancy COPD DM Immunosuppressants SSI Loss of domain hernias  Abdominal contents can no longer stay in the cavity and protrude With loss of domain hernias, natural rigidity of abdominal wall becomes compromised and abdominal musculature is retracted. Results of loss of domain Respiratory dysfunction Bowel edema Stasis of splanchnic circulation Urinary retention Constipation

63. Width of the hernia and presence of contamination are the 2 variables associated with wound morbidity and hernia recurrence. Hernia classification using width and wound class alone

64. Management of ventral hernia Primary done is done when Hernia is <3 cm diameter Viable surrounding tissue Hernia created by technical error in previous operation Prosthesis (E.g. Mesh) Hernia > 3 cm in diameter Prosthetic materials used for hernia repair Permanent synthetic materials Characteristics of an ideal mesh Chemically inert Resistant to mechanical stress Sterilizable Compliant Non carcinogenic Non inflammatory Hypoallergenic [@ CRS-CNN-H]

65. 1.Permanent synthetic mesh Consider position of the mesh Presence of risk of infection Mesh can be classified on the basis of Weight of material Pore size (Macro/ microporous) Water angle (hydrophobic/ hydrophilic) Whether adhesive barrier is present/not Choice of mesh Extraperitoneal  microporous, unprotected mesh, prolene/polyester mesh Intraperitoneal Various options are available [See next slide] Mesh Weight Lightweight < 40g/m 2 Medium weight 40-60 g/m 2 Intermediate weight 60-75 g/m 2 Heavy weight >75 g/m 2 Lightweight vs heavyweight  Lightweight is favored When recurrence is the issue  Heavyweight is favored Bacterial contamination Large pore synthetic mesh is used [ animal studies] Complex ventral hernias Polyester mesh (microporous mesh)

66. 2. Biological mesh Nonsynthetic, natural tissue mesh Classified as Source  Human/ Porcine/ Bovine Postharvest processing Cross-linked/non-cross-linked Sterilization techniques Gamma radiation, Ethylene oxide gas Contain acellular collagen make it suitable to be used in infected/ contaminated cases. Function best when used as fascial reinforcement rather than bridge or interposition repair 3. Absorbable synthetic mesh Polyglactin used to construct absorbable synthetic mesh Mesh can be placed in any plane but typically with soft tissue covering mesh anteriorly Can be used in contaminated complex ventral hernia repair

67. Operative techniques in Ventral Hernia

68. Sublay may be further of Rectorectus ( Rectomuscular ) Preperitoneal Intraperitoneal Highly desirable to place mesh beneath the fascia. 1. Intraperitoneal mesh placement Composite mesh 4 cm fascial- mesh overlap Interrupted mattress suture Mesh placement may be Onlay Interposition (Inlay) Sublay

69. 2. Myofascial releases Fascial layer is separated from the muscular layer in the abdominal wall Basic principle Abdominal wall and rectus muscle are bounded by several different myofascial compartment By releasing one or more fascial bundles, advancement of the rectus muscle to the midline is possible Each of these procedures creates a local advancement flap of the rectus muscle 3. Posterior rectus sheath incision with retromuscular mesh placement [ Stoppa repair] A prosthetic mesh is placed in extraperitoneal position in preperitoneal space or retro rectus position Mesh placed on top of posterior rectus sheath or peritoneum Mesh extends 5-6 cm beyond superior and inferior borders of the defect

70. 4. Component separation Posterior component separation Also called as transversus abdominis release Prerequisites Tobacco free 1 month prior and 2 months after surgery Albumin > 3.5 g/dl HbA1C <7.0 Pre-habilitation, 30 mins of walk per day BMI < 35 Steps of posterior component separation Incision and adhesiolysis Packing of content Incision of posterior rectus sheath Retrorectus dissection Transversus abdominis release Retromuscular dissection Posterior rectus closure (Zip sign) Patch with Vicryl mesh TAP block Mesh deployment Closure of midline Skin closure

71. Anterior component separation Involves separating the lateral muscle layer of the abdominal wall to allow their advancement Anterior component separation done on both sides allow a mobilization of 20 cm Too lateral advancement can lead to lateral bulging or lateral herniation Steps of anterior component separation Raise large subcutaneous flap above EOM fascia Flaps retracted laterally past linea semilunaris Preserve perforators to SC flaps Relaxing incision is given 2 cm lateral to Linea semilunaris on lateral EO aponeurosis superiorly from subcostal margin to pubis Blunt separation of EOM from IOM

72. Some unusual hernias a. Spigelian hernias Hernia between rectus muscle and semilunar line Caused by absence of posterior rectus fascia. Hernias are often interparietal with hernia sac dissecting posterior to the EO aponeurosis Small hernias (1-2 cm) 4 th to 7 th decade USG/CT based diagnosis Repaired by primary/ mesh repair Open/ Laparoscopic technique can be used b. Obturator hernia Patients present with evidence of compression of the obturator nerve which causes pain over anteromedial aspect of the thigh (Howship-Romberg sign) Pain relieved by thigh flexion Bowel obstruction is present CT based diagnosis Repaired by: Posterior approach Hernia reduced Preperitoneal fat pad within canal reduced Obturator foramen is repaired with prosthetic mesh.

73. c. Lumbar Hernia Occur in region of posterior abdominal wall. MC  Male, left side May occur through superior and inferior lumbar triangle Superior lumbar triangle (Grynfelt triangle) herniation is more common Cause: Weakness in lumbodorsal fascia Lumbar hernia doesn’t strangulate Repaired by mesh placement which is sutured beyond the margins of the hernia (Dowd’s operation) Grynfelt triangle : Bounded by (@ 12 PI) 12 th rib Paraspinal muscles Internal oblique muscle Petit triangle : Bounded by (@ LIE) Latissimus dorsi Iliac crest EOM

74. Loss of domain hernias Massive hernias in which the herniated contents cannot be replaced into the peritoneal cavity Types: With pre-operative contamination Without pre-operative contamination Also classified as Small hernial defect [ t/t  PPP] Massive hernial sac [t/t  PTFE dual mesh] Management Careful pre-op evaluation Follow pre-requisites for component separation For large hernias staged approach using PTFE dual mesh and lateral retraction of abdominal wall musculature is done Initial stage  reduction of hernia, placement of large PTFE dual mesh, suture mesh to fascial edge Subsequent stage serial excision of the mesh until fascia can be approximated Finally, mesh completely excised and fascia reapproximated by component separation and biologic underlay patch

75. Other management technique of LOD hernias

76. Parastomal hernia Incidence of stomal hernia is more for colostomies and is approximately 50% Routine repair of parastomal hernias is not recommended Indications Bowel obstruction Problems with pouch fit Cosmetic issues Repair approaches Primary fascial repair Stoma relocation Prosthetic repair Primary fascial repair  hernia reduction and fascial reapproximation through peristomal incision. High recurrence rate Prosthetic repair (using mesh) Has excellent long term results with lower hernia recurrence. Complications Erosion Obstruction Approach Onlay Intraabdominal / Intraperitoneal Retrorectus

77. Techniques of parastomal hernia repair Sugar baker procedure (Mesh flap) Mesh placed intraperitoneally Stoma placed as flat sheet/ keyhole fashioned around the stoma Lateralize the stoma as it exits the abdomen Rectomuscular repair (keyhole mesh repair) Laparotomy performed Stoma taken down Resited to contralateral abdomen Posterior component separation done Large mesh placed in retromuscular area to cover old stoma site, new midline incision and reinforce new stoma site Stoma brought out through keyhole incision in mesh and matured.

78. Miscellaneous information Seroma formed after mesh placement should be extracted only after 6-8 weeks. Drain placement can be done to reduce seroma formation. Mesh infection: 2 types of presentation Acute with sepsis Chronic indolent infection Acute cases Admission IV antibiotics Early debridement and mesh removal Chronic cases Per cutaneous drainage of fluid Antibiotic suppression CT scan to assess resolution of fluid  if low volume of fluid drain is removed

79. Thankyou…