Umbilical Paraumbilical Hernia- Saral

Case Presentation & Discussion on Umbilical Paraumbilical Hernia

1. CASE PRESENTATION Department of General Surgery Saral Lamichhane 2074/05/15

2. Patient Details: Basudev Dhakal , 34 years/Male from Chapakot , Syangja Hinduism, Foreign employment (hotel) Date of admission: 9 days back via OPD Date of discharge: 3 days back Chief Complaints: Mass protruding just above umbilicus for 1 year 2

3. History of presenting complaints: Mass protruding just above umbilicus in midline for 1 year Painless, Progressive D ecreases on supine, increases on standing or activity No history of abdominal pain, vomiting No history of chronic cough, constipation Normal bowel habit No urinary complaints 3

4. Past medical history: - No history of hypertension, DM, TB Past surgical history: - No previous surgical interventions Personal history: - Nonsmoker, non alcoholic, non vegetarian Family history: - Similar history in younger brother Socioeconomic history: - Middle class status 4

5. Clinical Examination: Vitals: Blood pressure: 110/70 mmHg Pulse: 78/min, regular Temperature: Afebrile Respiratory rate: 14/min, regular General examination: Pallor: Absent Icterus: Absent Cyanosis: Absent Clubbing: Absent Lymphadenopathy:Not palpable Edema: Absent 5

6. Abdominal Examination: Soft, non tender, no palpable organomegaly Inspection: Approx. 2×2 cm swelling 1 cm above umbilicus in midline, Palpation: Soft, 2×2 cm swelling, reducible, non transilluminant , nontender , cough impulse positive Percussion: Dull 6

7. Respiratory System: Bilateral Normal Vesicular Breath Sounds Cardiovascular system: S1 S2 M0 Central nervous system: - Grossly intact Clinical diagnosis: Reducible Paraumbilical Hernia 7

8. Investigations: Laboratory: Hb : 9.9 g/dl WBC : 4.6 × 10 9 /l Platelets : 190 ×10 9 /l - RBS : 104 mg/dl S. Urea : 30 mg/dl SGPT (ALT) : 27 U/L Serology : HBsAg spot, HCV spot, HIV I& II spot: Non-Reactive BT : 2’15” mins / CT : 7’30” mins PT, INR : 1.0 Radiological: USG ( abdomen+pelvis ): Paraumbilical hernia with defect size 14.1 mm, Fatty liver Chest X-Ray PA view : Normal ECG : Normal 8

9. Surgery: Hernioplasty under General Anesthesia Procedure: Anatomical repair done with 1-0 prolene Subcutaneous mesh placed Mininvac drain kept Findings: - Approx 2cm defect on supraumbilical region containing omentum 9

10. Postoperative management: NPO for next 6 hours Inj D 5 II pints + NS II pints over 24 hours Inj. Ceftriaxone 1 g iv BD Inj. Aciloc 50 mg iv TDS Inj. Tramadol 50 mg iv TDS Inj. Ondem 4 mg iv TDS Postop Day 2: Tab. Proxitab 1 tab po TDS, Tab. Raboss 20 mg po BD Postop Day 5: Minivac drain removed Complications: None 10

11. UMBILICAL/PARAUMBILICAL HERNIA 11

12. Introduction: A hernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls . Umbilical hernia is the herniation at the site of umbilicus. Paraumbilical hernias are the midline primary abdominal wall hernias from 3 cm above to 3 cm below the umbilicus. - European Hernia Society Contents: Preperitoneal fat tissue, Omentum , Small intestine, Combination Incidence: 10% of abdominal wall hernias 12

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14. Umbilicus anatomy 14

15. 15 Umbilical hernia

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17. Etiology: Infantile/congenital umbilical hernia: Delay in closure of umbilical ring Acquired umbilical/ paraumbilical hernia: Increased intra-abdominal pressure most important Obesity M ultiple pregnancies/labor Ascites Abdominal tumors 17

18. Clinical Features: Infantile Umbilical Hernia: - Upto 10 % of infants (higher in premature babies) - Appears within a few weeks of birth; often symptomless Umbilical mass Increases on crying to a classical conical shape - Obstruction and/or strangulation extremely uncommon < 3 years 18

19. Acquired umbilical/ paraumbilical hernia: Females > Males, commonly overweight Mass above or below umbilicus ( paraumbilical ) Protruding mass at the umbilicus (umbilical) Crescent shape appearance of umbilicus Painless or dragging pain due to tissue tension/obstruction Firm & dull on percussion ( Omentum ) Soft & resonant on percussion ( bowel) Reducible or irreducible Cough impulse present (reducible) 19

20. Complications Higher due to narrow neck & fibrous edge of defect Irreducibility Incarceration B owel obstruction Strangulation Skin ulceration 20

21. Management: Congenital Umbilical Hernia : - Parental reassurance: 95% resolve spontaneously by 2 years - Coin strapping: a historical technique, increases risk of strangulation - If persists beyond two years, surgical repair is indicated 21

22. Acquired umbilical/ paraumbilical hernia: Small asymptomatic: leave D efects < 1 cm: - Simple figure-of-eight suture - Repaired by a darn technique Defects upto 2 cm: Mayo’s vest over pants repair - Minimal tension primary suturing A transverse incision made, hernia sac dissected, opened & content reduced Any non-viable tissue removed, peritoneum closed Defect in anterior rectus sheath extended laterally on both sides & elevated to create an upper and lower flap. L ower flap inserted beneath the upper flap & sutured to it (double breasted) S uction drain placed to reduce seroma & haematoma in subcutaneous space 22

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24. Defects > 2 cm: Mesh repair Within the peritoneal cavity : Intraperitoneal/Underlay mesh - tissue separating mesh through the defect, fixed with an overlap of 5 cm In the extraperitoneal space: Preperitoneal mesh - plane below posterior rectus sheath, just outside the peritoneum - linea alba closed over the mesh - In the retromuscular space: Sublay mesh - linea alba opened vertically, posterior rectus sheaths sutured together - rectus muscles elevated to form retromuscular space for mesh - mesh overlaps midline by 5 cm laterally 24

25. - Within the defect: Inlay mesh - Only applies to mesh plugs in small defects, high recurrence - In the subcutaneous plane: O nlay mesh - Simplest open repair - Close linea alba vertically with sutures - M esh on the anterior rectus sheath and sutured to it - P rone to infection, seroma Laparoscopic umbilical hernia repair: - Contents of hernia reduced by traction & external pressure - Non-adherent mesh for intraperitoneal use, fixed to peritoneum & posterior rectus sheaths using staples, tacks or sutures Posterior, Anterior component separation: for giant/complex hernias 25

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27. Emergency repair: In cases of simple incarceration without clinical evidence of strangulation , repair may be attempted laparoscopically . Mostly performed by open surgery In the presence of established strangulation: - Open sutured repair done - No mesh because of the risk of infection - Two-stage repair: initially, hernia contents being dealt with and subsequent definitive mesh repair once sepsis controlled 27

28. Recurrence: Large seroma and surgical site infection  P atient’s BMI >30 kg/m 2  and defects >2 cm Smoking C irrhosis and with uncontrolled ascites Surgical technique 28

29. Updates: The use of mesh results in decreased recurrence & similar wound complication rates compared with tissue repair for primary umbilical hernias.  Umbilical hernias should be repaired using mesh, especially if a patient has multiple comorbidities associated with recurrence (obesity , diabetes, liver disease, ascites). (JAMA Surg. 2017 Jan 25. doi: 10.1001) There is a high probability that sublay repair is associated with the fewest SSIs and hernia recurrences. T opical gentamicin in addition to preoperative intravenous prophylaxis to lower the infection rates after hernia repairs as umbilicus is dirty than inguinal region. Decreased total & wound morbidity with Laparoscopic Hernia Repair for elective primary umbilical hernia repairs at the expense of increased operative time. 29

30. TAKE HOME MESSAGE………… Midline primary abdominal wall hernias within 3 cm of umbilicus Infantile: due to delay in closure of umbilical ring Acquired: due to increased intraabdominal pressure Painless, reducible mass above, below or at umbilicus Pain, irreducibility suspicious of complications Infantile: 95% resolve by 2 years age Acquired: Upto 2 cm defect: Primary suturing, Mayo’s vest over pant repair More than 2 cm: Open Mesh repair ( Onlay , Inlay, Sublay , Intraperitoneal) Laparoscopic umbilical hernia repair Mesh repair ( sublay ) has less recurrence Laparoscopic repair has less total & wound morbidity 30

31. Bibliography: Sabiston Textbook of Surgery The Biological Basis of Modern Surgical Practice, 20th Edition (2016) Bailey and Love’s Short Practice of Surgery, 26 th Edition, 2013, Taylor & Francis Group, CRC Press Frank H Netter, Atlas of Human Anatomy, 6 th Edition Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al. Classification of primary and incisional abdominal wall hernias. Hernia.  2009;13:407–414 Current options in umbilical hernia repair in adult patients, Hakan Kulaçoğlu , Ulus Cerrahi Derg . 2015; 31(3): 157–161 . Deysine M. Infection control in a hernia clinic: 24 year results of aseptic and antiseptic measure implementation in 4,620 “clean cases” Hernia. 2006;10:25–29. Aslani N, Brown CJ. Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis. Hernia. 2010;14:455–462. Mesh Location in Open Ventral Hernia Repair: A Systematic Review and Network Meta-analysis, World J Surg , 2015, DOI 10.1007/s00268-015-3252-9 Cassie S, Okrainec A, Saleh F, Quereshy FS, Jackson TD. Laparoscopic versus open elective repair of primary umbilical hernias: short-term outcomes from the American College of Surgeons National Surgery Quality Improvement Program.  Surg Endosc .  2014;28:741–746 Classification of primary and incisional abdominal wall hernias, Hernia (2009) 13:407–414 http://emedicine.medscape.com/article/2000990-overview Google images accessed on 11:12 pm, 8/27/2017 31

32. THANK YOU !!!!

33. Management: A. Prosthetic repairs   1. Open approach     a. Onlay mesh     b. Sublay/Preperitoneal mesh     c. Mesh plug     d. Bilayer prosthetic devices   2. Laparoscopic approach     a. Inlay mesh     b. Defect closure and mesh placement B. Tissue–Suture repairs   1. Primary suture   2. Mayo repair 33