Incisional hernia management in surgery.pptx

contains etiology classification and management of incisional hernia

1. REPAIR OF INCISIONAL HERNIA Dr. Saujanya Jung Pandey Resident General Surgery

2. The muscles of the abdominal wall: ✔ Medially : Rectu s abdominu s and ✔ Laterally : Externa l oblique, internal oblique, and transversus abdominis

3. Sabiston’s textbook of surgery-21 st Edition

4. EPIDEMIOLOGY Incisional hernia occurs in approximately 10 to 15 percent of patients with a prior abdominal incision(1) The incidence depends upon the location and size of the incisions Incisional hernias can also develop at some laparoscopic trocar sites Nachiappan S, Markar et al.Prophylactic mesh placement in high-risk patients undergoing elective laparotomy: a systematic review. World J Surg. 2013 Aug;37(8):1861-71. doi : 10.1007/s00268-013-2046-1. Erratum in: World J Surg. 2013 Jul;37(7):1747. Karthikesaligam , Alan [corrected to Karthikesalingam , Alan]. PMID: 23584462.

5. A meta analysis of 11 studies examining the incidence of ventral hernia formation after various types of abdominal incisions has concluded that the risk is 10.5% for midline, 7.5% for transverse, and 2.5% for paramedian incisions Carlson MA, Ludwig KA, Condon RE. Ventral hernia and other complications of 1,000 midline incisions. South Med J . 1995;88:450–453.

6. Risk factors Patient factors  old age obesity smoking malnutrition immunosuppressive therapy and connective tissue disorders Technical factors Wound infection Suboptimal fascial closure Abdominal fascial dehiscence Type of abdominal surgery

7. CLASSIFICATION Incisional hernias can be classified by anatomical or clinical criteria. Anatomical classification: The European Hernia Society (EHS) classification for incisional abdominal wall hernias divides the abdomen into a medial zone and a lateral zone

8. Anatomical classification: The medial zone: defined as medial to the lateral margin of the rectus sheath It is subdivided into five subzones ( subxiphoid , epigastric, umbilical, infraumbilical , and suprapubic). The lateral zone is subdivided into four subzones (subcostal, flank, iliac, and lumbar) 

9. European Hernia Society Classification

10. CLASSIFICATION As an indication of its size, the width of a hernia is classified into three categories of <4 cm, 4 to 10 cm, and >10 cm  Clinical classification : Based on the clinical presentation, incisional hernias can be asymptomatic, reducible, incarcerated, or strangulated. A population study of over 23,000 patients undergoing nonoperative management of an incisional hernia reported a cumulative incarceration rate of 1.24 percent at one year and 2.59 percent at five years* Although rare, incarcerated incisional hernia can be associated with a high all-cause mortality (7.2, 10, and 14 percent at 30, 90, and 365 days, respectively). * Dadashzadeh ER, Huckaby LV, et al. The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients. Ann Surg. 2022 Feb 1;275(2):e488-e495. doi : 10.1097/SLA.0000000000003916. PMID: 32773624; PMCID: PMC8917417.

11. Clinical features of incisional hernia Localized swelling or diffuse bulging Peristalsis may be seen in the underlying intestine Dermatitis Partial intestinal obstruction are common Strangulation is less frequent (broad-necked)

12. Combined from Ventral hernia working group grading scale and EHS classification (table) The Ventral hernia working group grading scale uses patients comorbidities and wound class to predict SSO risk EHS assesses hernia width and location.

13. DIAGNOSIS clinically in most patients without obesity computed tomography (CT) of the abdomen and/or pelvis to confirm the presence of a hernia and identify any contents that might be contained within the hernia sac

14. Treatment of incisional hernia Asymptomatic incisional hernias: ✔ may not require treatment at all. ✔ The wearing of an abdominal binder or belt Operative repair: ✔ Small (≤2–3 cm in diameter): Primary repair ✔ Larger defects (>2–3 cm in diameter): are repaired with a mesh

15. MESH repair The lightweight mesh < 40 g/m2; medium weight mesh, 40 to 60 g/m2; and intermediate weight mesh, 60 to 75 g/m2 with heavy weight mesh weighing more than 75 g/m2. These lightweight mesh products often have an absorbable component of material that provides initial handling stability, typically composed of Vicryl ( polyglactin 910) or Monocryl ( poliglecaprone 25; Ethicon, Somerville, NJ).

16. In a randomized controlled trial evaluating lightweight versus heavyweight polypropylene mesh for ventral hernia repair, the recurrence rate in the lightweight group was more than twice that in the heavyweight group (17% for lightweight mesh vs. 7% for heavyweight mesh), which approached statistical significance (P = 0.052). (1) In a recent randomized controlled trial, heavyweight mesh has been shown to exhibit less recurrence and chronic pain 2 years after laparoscopic TEP inguinal repair compared to lightweight mesh. (2) Burgmans JP, Voorbrood CE, Simmermacher RK, et  al. Long-term results of a randomized double-blinded prospective trial of a lightweight ( Ultrapro ) versus a heavyweight mesh ( Prolene ) in laparoscopic total extraperitoneal inguinal hernia repair (TULP-trial). Ann Surg. 2016;263:862–866. Melkemichel M, Bringman SAW, Widhe BOO. Long-term comparison of recurrence rates between different lightweight nd heavyweight meshes in open anterior mesh inguinal hernia repair: a nationwide population-based register study. Ann Surg. 2019.

17. Prosthetic material Three general categories of mesh used in the repair of ventral hernias are synthetic mesh, biologic mesh, and biosynthetic mesh Permanent Synthetic Materials: Synthetic meshes are either woven from an extruded monofilament ( eg , polypropylene or polyester) or created from expanded polytetrafluoroethylene ( ePTFE ) and can be subcategorized by weight/density (ultra-lightweight to super-heavy weight) as well as by material; composition; pore characteristics; and mechanical parameters, including tensile and burst strength, elasticity, and stiffness In extraperitoneal position: macroporous unprotected mesh is appropriate like polypropylene and polyester

18. Intraperitoneal position: A single sheet of mesh with both sides constructed to reduce adhesions and a composite-type mesh with one side made to promote tissue ingrowth and the other to resist adhesion formation are available composed of expanded polytetra fluoroethylene ( ePTFE ). This prosthetic has a visceral side that is microporous (3 μm ) and an abdominal wall side that is macropoous (17–22 μm ) and promotes tissue ingrowth.

19. Biologic Materials Nonsynthetic , natural tissue mesh These products can be categorized on the basis of the source material (e.g., human, porcine, bovine), postharvesting processing techniques (e.g., cross-linked, non–cross-linked), and sterilization techniques (e.g., gamma radiation, ethylene oxide gas sterilization, nonsterilized ). These products are largely composed of acellular collagen and theoretically provide a matrix for neovascularization and native collagen deposition Advantages in infected or contaminated cases in which synthetic mesh is thought to be contraindicated

20. Absorbable Synthetic Materials Long-acting resorbable meshes are synthetically derived products with resorption profiles between 6 and 36 months. Polyglactin Variations of this material have been produced, resulting in slower hydrolysis and better handling characteristics at the time of implantation. In a prospective case series, slowly resorbable polyglactin mesh was found to have an acceptable recurrence rate of 17% when placed in a retromuscular position during contaminated complex ventral hernia repair* *Rosen MJ, Bauer JJ, Harmaty M, et  al. Multicenter, prospective , longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: the COBRA Study. Ann Surg. 2017;265:205–211.

21. Mesh location The mesh can be placed above the fascia ( onlay ), between the rectus muscles and peritoneum/posterior rectus sheath ( sublay ), below the peritoneum (underlay or intraperitoneal onlay ), or in between fascial edges (inlay)

22. Mesh size The mesh used for ventral hernia repair should be sufficiently large to permit >2 cm overlap for open repair of small primary ventral hernias (<1 cm in diameter) >3 cm overlap for open repair of medium primary ventral hernias (1 to 4 cm in diameter) >5 cm overlap for open repair of large primary ventral hernias (>4 cm in diameter) or ventral incisional hernia and >5 cm overlap for all laparoscopic repairs Henriksen NA, Montgomery A, et al. European and Americas Hernia Societies (EHS and AHS). Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg. 2020 Feb;107(3):171-190. doi : 10.1002/bjs.11489. Epub 2020 Jan 9. PMID: 31916607.

23. Mesh versus nonmesh repair   For all ventral hernias with a defect >1 cm in a clean field, a mesh repair is preferred over nonmesh repair Mesh is a required element of all laparoscopic or robotic ventral hernia repairs and has been shown to decrease recurrences after open ventral repair of various types of ventral hernias On the other hand, mesh repairs are associated with a higher rate of wound complications including infections than repairs without mesh

24. Operative Technique repaired with sutures, mesh, component separation, or any combination of the above. Simple suture repair is performed using an open approach Mesh repair and component separation can be performed open, laparoscopically, or robotically.

25. Myofascial releases Fascial layer being separated from a muscular layer in the abdominal wall. To reestablish the linea alba Protects the mesh from superficial wound issues, and might result in a more durable repair.

26. COMPONENT SEPARATION Ramirez first described the term ‘component separation’ in 1990 as a way large abdominal wall defects can be reconstructed with functional transfer of abdominal wall components. Purpose of component separation: Relieve tension on midline fascial closure Facilitate the retromuscular mesh placement

27. Techniques of component separation Anterior component separation Posterior component separation Both allow for a maximum bilateral rectus advancement of approx. 20 cm TAR (transversus abdominis release) allows significant posterior fascial advancement > 20 cm Both component should not be performed concomitantly

28. Anterior component separation separating the lateral muscle layers of the abdominal wall to allow their advancement. Primary fascial closure at the midline is often possible. Performed by raising large subcutaneous flaps above the external oblique fascia Flaps are carried laterally past the linea semilunaris Relaxing incision is made 2 cm lateral to the linea semilunaris on the lateral external oblique aponeurosis from several centimeters above the costal margin to the pubis

29. Although this technique often allows tension-free closure of these large defects, recurrence rates as low as 20% have been reported with the use of prosthetic reinforcement in large hernias To date, no randomized controlled trials have supported a lower recurrence rate with biologic prosthetic reinforcement. If a bioprosthetic is placed, it can be secured with an underlay or onlay technique. No comparative data exist demonstrating the superiority of either repair technique.

30. Posterior component separation In larger hernias or in those patients with atrophic narrowed rectus muscle Rives- Stoppa retrorectus dissection TAR

31. Rives- Stoppa retrorectus dissection In 1980s by Jean Rives and rene stoppa , french Medial division of posterior rectus sheath Lateral extents is limited by linea semilunaris

32. transversus abdominis release (TAR) Division of TA muscle, conferred the name TAR advancement can be obtained by incising the posterior rectus sheath approximately 1 cm medial to the linea semilunaris . At this location, the posterior leaflet of the internal oblique and the transversus are incised to gain access to either the pretransversalis plane or the preperitoneal space. Provide adequate mesh overlap and facilitate posterior sheath closure Well vascularized plane

33. Indication for TAR Large or complex hernia Subxiphoid hernia Parastomal hernia Flank hernia Suprapubic hernia

34. Choosing a surgical approach Open versus laparoscopic repair Robotic versus laparoscopic repair

35. Open versus laparoscopic repair Several prospective randomized trials have compared laparoscopic and open ventral hernia repairs Although most of these studies were small, with fewer than 100 patients, the results tend to favor a laparoscopic approach for small to medium sized defects. The incidence of postoperative complications and recurrence were less in hernias repaired laparoscopically

36. Robotic versus laparoscopic repair Two trials published so far mostly < 4cm showed the robotic repair with intraperitoneal mesh had similar outcome to its laparoscopic counterpart. Required longer operative time and higher cost.

37. References Williams N, O’Connell PR, McCaskie AW. Bailey & Love’s Short Practice of Surgery . 27 th edition. Florida (US): CRC Press; 2017. Chapter 60, Abdominal wall, hernia and umbilicus; p. 1022-46. Townsend CM et al. Sabiston: Textbook of Surgery: The Biological Basis of Modern Surgical Practice . 21 st edition. Missouri (US): Elsevier; 2022. Chapter 45, Hernia; p. 1105-33

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