Transcript Hernia surgery

Brandon H. Kilgore, MD, FACS
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A defect or hole allowing contents of one cavity
to pass into another cavity or potential space
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Most commonly, this hole occurs in the
fibromuscular tissues comprising the abdominal
wall
This is an anatomic problem requiring surgery for
definitive treatment.
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Inguinal
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Direct
Indirect
Femoral
Umbilical
Incisional
Traumatic: Lumbar
Repetitive strain: “Sports Hernia”
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Relative ‘weakness’ of tissue
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Openings or previous openings in the abdominal
wall (or canal where a structure perforates the wall)
 Groin: spermatic cord or femoral vessels
 Umbilicus: umbilical cord
 Any incision: scar is weak relative to native tissue
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Any activity that increases intra-abdominal
pressure - thereby increasing abdominal wall
tension - may contribute to development of
hernia signs or symptoms
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Heavy lifting, coughing, straining, strenuous activity
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Bulge
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May be obscured in obese individuals
Natural history: enlarge over time
Pain
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Usually caused by stretching of the hernia ring
 Improved by ‘reduction’ of the hernia ‘contents’
 Worse in evening, after upright, after straining
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Diagnosis: description of symptoms, physical
exam (sometimes imaging)
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Incarceration
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Hernia contents get stuck – and cannot be reduced
 Requires EXPEDITED surgery
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Obstruction
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When bowel is extruded through a hernia and becomes so tight
that food cannot pass through that segment
 Causes severe pain, nausea, vomiting
 Requires URGENT surgery
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Strangulation
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When hernia contents – especially bowel – become stuck so
tightly that adequate blood flow cannot reach these contents
 Causes necrosis (death) of the strangulated contents
 Eventually results in perforation, peritonitis, sepsis, and death
 Requires EMERGENT surgery
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Complications of hernia
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Symptoms of hernia
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Potentially incapacitating or life-threatening
Lifestyle- and productivity-limiting
Presence of hernia
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Potential for development of complications
 Greatest potential: new, small, femoral, recurrent, scrotal
 Otherwise difficult to predict who will experience
complications (2.8% @ 3mo, 4.5% @ 2y; 0.0018 hernia-related
adverse events / patient-year)
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Potential for development of symptoms
 Asymptomatic groin hernias may be followed, but a quarter
to a third become symptomatic within 2-4 years.
 Impaired perception of health or ?decreased productivity
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Tension = Recurrence
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Suture repair = Tension
 Forces are concentrated at the suture line
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Mesh = minimal tension  standard of care
 Distributes tension over the surface area of the mesh
 Less pain than suture repair
 Prosthetic (woven plastic lattice) mesh: more durable
 Allows ingrowth of tissue (incorporates into the tissue)
 Less dependent upon tissue healing for success
 Few exceptions: contamination, small umbilical hernia
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Open (anterior)
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Single incision directly overlying the abnormal anatomy
 Dissection is distant from bowel and vasculature
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Mesh is sutured anterior to the fascia
Recurrence rates are thought to be lower (<5%)
 Improved durability may be preferable for manual laborers
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Pain may be greater up to 2 weeks
Laparoscopic (posterior)
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Multiple incisions distant from anatomy
 Potential for incisional hernia in addition to recurrence
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Mesh is tacked posterior to fascia
Potential for rare but serious complications
Recurrence rates are thought to be higher (up to 10%)
Pain may be less in first 2 weeks
 Possible earlier return to work for sedentary workers (~1 day)
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Reconstruction of normal anatomy
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Reduce or excise hernia contents
Excise hernia sac
Excise scar
Reapproximate native tissues under minimal tension
 May require component separation
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Mesh reinforcement
Posterior prosthetic mesh
 Anterior biological mesh
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Meticulous wound closure
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Excise redundant tissue
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Umbilical
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Suture repair if small
Fascial closure over mesh ‘patch’
?laparoscopic
Incisional
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Laparoscopy
 Unable to reestablish native anatomy
 Hole remains, but excluded from abdomen
 Possible seroma formation
 Less pain & decreased length of recovery
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Open
 Combined suture closure and(?dual) mesh reinforcement
 Greater potential for wound complications
 Longer in-hospital and at-home recovery
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Surgery will not be at the time of initial visit
Initial visit will include history, examination,
discussion of options, and explanation of risks.
Request that patients bring the following:
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List of previous medical conditions and surgical
interventions
List of current medications and allergies
If pt has had previous surgery for hernia, please
bring operative reports.
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Preoperative prohibitions
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Timing
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Eating or drinking after midnight
Aspirin, plavix, coumadin, pradaxa, etc.
Smoking
Admitting & pre-op prep: ~1.5 hours
Surgery: 1-1.5 hours
Recovery Room: 1-2 hours
Outpatient Surgery Recovery: 2-6 hours
Postoperative checklist
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Pain and nausea control
Tolerate liquids
Ambulatory
Urinate
Ride home
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Medical risks of anesthesia & surgical stress
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Heart attack, stroke, kidney failure, blood clot,
pneumonia, abnormal heart rhythm
Infection & wound complications
Bleeding
Mesh complications
Recurrence
Nerve injury(numbness & chronic pain)
Urinary retention
Risks of intra-abdominal surgery
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Bowel, bladder, vascular injury, etc.
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No driving for 2-3 days or while on narcotics
Swelling, bruising, and soreness are common
Keep wound clean & dry for 2 days – no
immersion for >1 week
Generally plan to avoid travel for 1 week
Diet is as tolerated but prudence is advised
Expect increased rest requirements
Ambulate multiple times a day
Ensure adequate bowel function
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Varies widely between people and procedures
Return to Work dependent upon:
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Laparoscopy & Umbilical hernia
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Type of procedure (open incisional v. umbilical)
Patient comorbidities (age, obesity, debilitation, etc.)
Availability of ‘light duty’ for 4-8 weeks
Pain should be much improved after 1 week
Return to work when stamina & pain allow (~1wk)
Open Inguinal Hernia
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Pain may last 2 days to 2 weeks
Return to work within 2 weeks given pain & stamina
 WC patients may experience greater time off work over those
with commercial insurance (34 days vs. 13 days)
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Tensile strength
The tendency of the wound to resist disruption
 Native, intact tissue > operated tissue / scar
 Increases with wound remodeling and collagen
deposition
 Proportional to time
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 Nears eventual strength at approximately 6 weeks
 Healing is slowed by tobacco use, diabetes, steroid
administration, etc.
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Need tensile strength to increase prior to activities
which would disrupt the repair:
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Heavy lifting & coughing > moderate lifting, bending,
straining > jogging, walking