Transcript Surgical Management of ventral and umbilical hernias

Surgical
Management of
ventral hernias
Jerry G Gaston DO FACOS
April 2014
Ventral hernias
• Epigastric
• Umbilical
• Spigelian
• Lumbar
• Littre’s
• Richter’s
• Amyand’s
epigastric
• Hernia of the linea albea between the xiphoid and
umbilicus
• Neurovascular bundles penetrate the linea albea
• Weakness of the linea albea
• 20% multiple and 80% off the midline
• 1.6% to 3.6% of all abdominal wall hernias
• 3 times more common in men
• Third to fifth decade of life
epigastric
• Epigastric pain from the compression of the
neurovascular bundle by the incarcerated fat
• Easily confused with lipomas
• Diagnosed with physical exam or in obese patients
obtain CT or Ultrasound
• High risk of incarceration and pain
• Fascia around the defect often thin and weak therefore
primary repair not advised unless defect 3 mm in size
• Open vs laparoscopic repair
Spigelian
• Between the lateral edge of the rectus abdominis
muscle medially and the semilunar line laterally.
• The hernia contents penetrate the transversus
abdominis and the internal oblique muscles but remain
behind the external oblique aponeurosis
• Almost always develop at the arcuate line or below it
• Mainly acquired hernias– increased intrabdominal
pressure
spigelian
• .12% - 2.4% of all abdominal wall hernias
• Higher incidence in women
• Small defect therefore high incidence of incarceration
• Difficult to palpate thus CT is often needed for
diagnosis
• Open vs laparoscopic repair
Lumbar
• Bounderies of the 12 th rib superiorly, the iliac crest
inferiorly, the erector spinae muscles posteriorly, and
the posterior border of the external oblique anteriorly
• Congenital or acquired
• Inferior lumbar triangle Petit’s triangle
• Superior lumbar triangle Grynfeltt-Lesshaft triangle
• Superior found in 93% cadavers
lumbar
• Bulge that increases with pressure
• 9% present with incarceration
• CT for high suspcious
• Repair open or laparoscopic in a lateral decubitus
position
• Large sheet of synthetic mesh as underlay, avoid plugs
• Rare so not many studies
Ideal “Mesh”
• Noncarcinogenic
• Chemically inert
• Resistant to mechanical strains
• Capable of being sterilized
• Inert to body and tissue fluids
• Capable of limiting foreign body reaction
• Amenable to fabrication in necessary form
• Unlikely to produce allergy or hypersensitivity reaction
• Minimize adhesions
• Resistant to infection
Shankaran V, et al. A review of available prosthetics for ventral
• Respond in vivo like autologous tissue
hernia repair Ann Surg, 2011
Permanent and
Absorbable Products
Permanent Barrier
•
Dualmesh®, DULEX™ (Gore and BARD)
•
•
100% ePTFE products
COMPOSIX™ LP and VENTRIO™ Products (BARD)
• ePTFE barrier
Absorbable Barrier
•
Proceed™ (Ethicon)
•
•
Physiomesh™ (Ethicon)
•
•
•
Porcine Collagen / Polyethylene Glycol (PEG) / Glycerol
C-Qur™ (Atrium)
•
•
Monocryl™
Parietex™ Composite (Covidien)
•
•
Oxidized Regenerated Cellulose
Omega-3 Fatty Acid cross-linked gel
SEPRAMESH™ IP Composite (BARD)
• Hyaluronic Acid / Carboxymethylcellulose / PEG
VENTRALIGHT™ ST Mesh (BARD)
• Hyaluronic Acid / Carboxymethylcellulose / PEG
Mesh
biologic
• Human acellular dermis
• Alloderm, Allomax, FlexHD
Porcine acellular dermis
CollaMend*, Permacol*, Strattice, XenMatrix, XCM
Porcine intestinal submucosa
FortaGen*, Surgisis
Mesh
biologic
Bovine acellular dermis (fetal)
SurgiMend,
Bovine Pericardium
• Peri-Guard, Tutopatch, Veritas
How I DO IT
1. Open primary repair
2. Open repair with mesh
3. Laparoscopic repair with mesh
How I DO It
• Open with primary repair
•
•
•
•
Thin young woman
Reoccurrence
No mesh
Smaller than a finger tip
How I do It
• Open with mesh
•
•
•
•
•
•
Small defect
Larger than fingertip
Mesh
Wound infection a bit higher
Less pain
Close defect?
HOW I DO IT
• Laparoscopic repair with mesh
• Close defect?
• Primary or incisional
• Previous infection
• Larger piece of mesh
• More pain
• Ileus
• Longer hospital stay
Component separation? Component vs bridge defect
Synthetic vs biologic
Fixation
Device Design:
Posterior Side
Low profile, thermoplastic polyurethane (TPU)
coated nylon balloon
Center of proximal
ends represent the
midline of the mesh
Tabs clearly identify
the connector
locations
Logo identifies long axis
Removal points marked
by arrows
31
Center of proximal
ends represent the
midline of the mesh
conclusion
• Mesh decreases reoccurrence
• Know previous hernia repair history ie op notes,
infection history
• Open mind….how to repair …..mesh selection