Incisional hernia

incisional hernia detail and its managment

1. Incisional hernia Dr Rana Pratap Singh Assistant professor Surgery Jss medical college

2. Anatomy of the Abdominal Wall

3. Function of Musculofascial Layers 5 paired muscles (3 flat, 2 vertical) 3 flat – int/ext oblique and transversalis Increase abdominal pressure to facilitate defecation, micturition, and parturition , Stabilizes trunk 2 vertical – rectus abdominus and pyramidalis Rectus - tensor of the abdominal wall,flexor of the vertebrae, stabilize the pelvis during walking, protects the abdominal viscera, aids in forced expiration

4. A na t o my

5. Ventral Hernia Any protrusion of viscera through anterior abdominal wall Categorized as spontaneous and acquired Spontaneous hernia: Umbilical and paraumbilical-71 % Epigatric-25% Others-4%

6. Acquired Hernia Incisional Laparotomy 89% Laparoscopy 5% Parastomal 6%

7. Umbilical Hernia: Umbilical hernia occurs when the umbilical scar closes incompletely in the child or fails and stretches in later years in the adult patient In infants Congenital and common Closes spontaneously by 2 years of age If persist after 5 years –surgical repair

8. In adults Largely acquired Female>male hernia does not protrude through umbilical cicatrix protrusion through the linea alba just above the the umbilicus -supraumbilical occasionally below the umbilicus (infraumbilical) – so called as paraumbilical hernia

9. Etiology M ultifactorial C ommonly found in association with processes that increase intraabdominal pressure pregnancy obesity ascites persistent or repetitive abdominal distention in bowel obstruction or peritoneal dialysis

10. Clinical Features Pain and swelling are the main symptoms Pain increases on prolonged standing or heavy exercise Content: mostly omentum

11. Treatment Reduce weight of the patient Treat the cause of ascites Mayo’s operation – vest over pants repair : imbrication of superior and inferior fascial edges For smaller defects – open umbilical hernia repair For larger defects - >2 cm – mesh repair – open or laparoscopic

12. Epigastric Hernia : Hernia protruding through interlacing fibres of the linea alba anywhere between umbilicus and xiphisternum P rotrusion of extraperitoneal fat – fatty hernia of linea alba Multiple in up to 20% of patients and approximately 80% are in midline

13. Etiology: Sudden strain leading to tearing of interlacing fibers of linea alba Clinical Features : Symptomless Painful- in partial strangulation of fat On palpation – feels firm , generaly no cough impulse and cannot be reduced

14. Treatment: Midline defect is usually elliptical in nature with the long axis oriented transversely Hernia will often not be seen on laparoscopy owing to the lack of peritoneal involvement through the hernia defect Open repair – excision of incarcerated preperitoneal tissue and simple closure of defect

15. INCISIONAL HERNIA It is herniation through a weak abdominal scar (scar of previous surgery). It is common in old age and obese individuals.

16. Predisposing Factors Vertical scar, midline scar, lower abdominal scar— may injure the nerves of the abdominal muscles. Scar of major surgeries (biliary, pancreatic). Scar of emergency surgeries (peritonitis, acute abdomen).

17. Faulty technique of closure. Poor nutritional status of the patient. Presence of cough, tuberculosis, jaundice, anaemia, hypoproteinaemia.

18. Malignancy , immunosuppression. Smoking in postoperative period. Causes which increases the intra- abdominal pressure (BPH, straining, stricture urethra or rectum, ascites).

19. Factors responsible for development of Incisional hernia Vertical incision has got higher chances of incisional hernia than horizontal incision Layered closure of the abdomen has got higher chance than single layer Continuous closure has got higher chances than interrupted closure

20. Using absorbable suture material has got higher chances of hernia than non-absorbable sutures . Emergency surgical wound has higher chances than elective surgical wound . Laparotomy for peritonitis, acute abdomen, and trauma can commonly cause incisional hernia .

21. Drainage through the main laparotomy wound may precipitate formation of incisional hernia Chronic cough, smoking, obstructive uropathy, constipation can precipitate incisional hernia

22. Diabetes , old age, malnutrition, malignancy, anaemia, hypoproteinaemia, jaundice, ascites, liver disease, uraemia, steroid therapy, immunosuppressive diseases are other precipitating factors

23. Clinical Features Swelling in the scar region . Pain . Impulse on coughing. Gurgling sound. Often bowel peristalsis may be visible under the skin.

24. Eventually features of irreducibility, obstruction , strangulation is seen. Hernia is common in lower abdomen. It may be small or large; huge or massive (diffuse)

25. Scar , its extent and location, whether healed primarily or secondarily , skin over the scar and swelling is noted. Details of the swelling with expansile impulse on coughing and examination both in lying down and standing are done . Gap cannot be assessed in an irreducible hernia.

26. defects in Incisional Hernia Small defect Large and wide defect Very large defect Massive / diffuse Multiple defects

27. Investigations: Always the precipitating factors must be looked for : Chest X-ray. U/S abdomen. Tests relevant for causes .

28. Complications of incisional hernia Irreducibility , Obstruction , Strangulation , Incarceration .

29. Treatment : Preventive measures Reduction of weight in obese before elective procedures Treat any respiratory diseases- chr.bronchitis Very careful closure of abdomen Single layer closure 5-8mm 5mm apart 2-0 suture 4:1 suture length All precautions to prevent immediate postoperative wound infection should be taken

30. Operative treatment: Primary repair Defect small <2cm Viable surrounding tissue Prosthetic repair Larger defect >2 to 3cm

31. Mesh placement options: Onlay technique: after primary closure of the fascial defect mesh is placed over the anterior fascia Advantages : no direct contact with viscera . Disadvantages : More chances of seroma formation superficial location of mesh- more prone for infection

32. Inlay technique : interposition of prosthetic mesh between the fascial edges . Very high recurrence rates Sublay / underlay technique : prosthetic mesh placed below the fascial components

33. Retromuscular technique : also called as Rives-Stoppa-Wantz Retrorectus Repair placement of mesh under the rectus muscle & above the posterior rectus sheath Advantage intraabdominal forces hold the prosthesis against the muscles. Forces that created the hernia now are used to prevent its recurrence

34. Component separation technique sk i n and subcutaneou s fat dissect e d free from the anterior sheath of the rectus abdominis muscle and the aponeurosis of the external oblique muscle. external abdominal oblique is incised 1 to 2 cm lateral to the rectus abdominis muscle .

35. E xternal oblique separated f r om the inter nal obl i que Dissection carried to posterio r axillary wall Additional length can be achieved by incising post rectus sheath above the arcuate line

36. L aproscopic surgical repair IPOM ( intraperitoneal onlay mesh) IPOM plus : IPOM + DEFECT CLOSURE L aproscopic TAR ( Transverse abdominis release) Robotic TAR

37. Disadvantages Higher operating cost Expertise needed

38. Parastomal hernia Common complication after stoma creation Incidence highest in colostomies-50% Usually asymptomatic Complications like bowel obstruction and strangulation rare Treatment : Primary fascial repair-recurrence Stoma relocation Prosthetic repair .

39. Thanks