hernia.pptx
- 1. Topic- Clinical Profile of Incisional Hernia and Minimally Invasive Approach Using Larger Mesh for Repair By Dr.Souparno & Dr.Hassan
- 2. Introduction • Hernia is a general term used to describe a bulge or protrusion of an organ through the structure or muscle that usually contains it. • Either congenital or acquired. • 80% of these acquired hernias result from previous surgery. • Its repair is one of the most common operation performed. • Reported in 11 to 20% of laparotomy incisions. • Laparoscopic approach has revolutionized the treatment of incisional hernia repair. • Recurrence is the most important clinical outcome of the incisional Hernia Repair. • Two technical details can minimise recurrence – sufficient overlap of the mesh, and the mesh fixation. • Further larger meshes have been advised covering the whole previous incision site as it has been observed that recurrence post repair occurs due to disregard for the principle that the entire incision- not just the hernia defect has a potential for hernia development.
- 3. Context • Incisional Hernia repair is commonly performed worldwide. • Minimally invasive approach for repair using composite mesh covering the entire previous incision can significantly reduce its most dreaded complications i.e recurrence.
- 4. Aim and objectives 1. To study the patient variable factors in correlation with the etiopathogenesis of incisional hernia. 2. To study the clinical outcome of incisional hernia with mesh covering the entire previous incision.
- 5. Materials and methods • Inclusion criteria- patients suffering from incisional hernia of either sex, more than 18 years of age who were fit for G/A. • Exclusion criteria- patients with age <18 years, hernial defect size > 15cm, obstructed hernia strangulated hernia, very large hernias (where there is no place for working trocars), morbid obesity with a large apron of fat (requiring abdominoplasty), densely scarred abdomen, Ascites, skin infection, enterocutaneous fistula and those not fit for G/A. • Selected patients suffering from incisional hernia were taken up in the study. Cessation of smoking was advised well in advance before the surgery. All the patient variable factors- age, sex, risk factors, mode of presentation and previous operation were analysed. Other risk factors- obesity, hypertension, diabetes mellitus, COPD, malignancy. These patients were made to undergo routine and special radiological investigations ie. CT scan/MRI were done to assess the exact defect size, contents and adhesions. Regarding the size of the mesh, whole of previous incision was measured keeping a 5-7 cm overlap of defect and length of incision.
- 6. Operative procedure • Intraperitoneal Onlay mesh repair with defect closure (IPOM PLUS) was done. • After administering general anesthesia pneumoperitoneum was created using a closed technique. • In most cases 10mm telescope was inserted which was followed by the placement of three trocars (5/10mm), forming one arc utilizing the “encirclement strategy”. • Adhesiolysis was carried out to visualize hernial defect by using endo-scissors or ultracision followed by reduction of contents. • In the case of difficult adhesiolysis, a hybrid technique in which a limited incision was made over the hernia sac was used. • The hernial defect was closed by continuous sutures at an interval of 1-2cm with 3-4 sutures in a retrograde manner using one number of Polydioxanone (PDS). • Composite meshes (polyester on the parietal side and collagen layer on the visceral side) were used. • The mesh was center aligned to overlap the incision intraperitoneally by 5-7cm circumferentially. • We used our innovative technique for transabdominal fixation every 3-5cm on the margins of the mesh. • Two Touhy (epidural no 16) needles were used: one was used for making an end loop of one number polypropylene and passed at the proposed site of fixation through a 1mm-2mm incision over the abdominal wall piercing through the mesh and the second needle carrying one number polydioxanone was passed through the same incision into the abdomen, keeping a distance of 1-2cm between the two needles and then was passed through the loop made the first needle with sufficient length of 7-10cm with the help of needle with sufficient length of 7-10cm with the help of needle holder and then both needles tied in 5-6 knots securely.
- 7. Postoperatively • Oral fluids were started on first post operative day and ambulation was allowed. • To wear abdominal binders for a minimum of 1 month. • Inclisional hernias were observed mostly in patients with history of obstetric and gynaecological procedures. • In 26 patients (40% casarean section 25% hysterectomy) followed by open cholecystectomy and laparotomy in 5 patients. • Lower midline incision was the commonest site for development of incisional hernia (40%) followed by transverse incisions (25%) and upper midline incision (7.5%). • On postoperative pain assessment using visual analog scale, 33 patients (82.50%) had moderate pain in the immediate postoperative period while others complaint of mild pain only.
- 8. Table 1 –Distribution of Patients, According to time of onset of hernia after surgery (months) Time of onset of hernia (in months) No. of Patients Percentage <5 months 7 17.5 7-12 months 11 27.50 13-18 months 7 17.5 18-24 months 5 12.5 > 24 months 10 25.0 Total 40 100
- 9. Table 2 –Distribution of Patients, According to Wound related complications Wound related complications No. of Patients Percentage Seroma 4 10.00 Wound infection 1 2.50 Port site cellulitis 1 2.50 Abdominal wall ecchymosis 2 5.00 No wound related complication 32 80.00 Total 40 100
- 10. Table 3 –Distribution of Patients, According to Quality of Life Assessment at 3 weeks Postoperatively Using Carolina Comfort Scale Quality of life No. of Patients Percentage < 10 13 32.50 11-20 10 25.00 21-30 9 22.50 31-40 4 10.00 41-50 2 5.00 51-60 1 2.50 > 60 1 2.50
- 11. Discussions • The repair of incisional hernia has been a challenging problem for which different techniques have been described. • Various series of study have shown the superiority of laparoscopic approach over the open approach for the incisional hernia repair in terms of quicker recovery time and less postoperative pain and it is now widely accepted. • Most patients (40%) in our study had previous surgeries using lower midline incisions most of whom underwent Obstetric and Gynaecological procedures similar to findings in studies where more than 50% of patients had lower midline incisions. • This may be because intra-abdominal hydrostatic pressure is higher. • Majority of the patients (75%) developed hernia within first 2 years of the previous surgery. • 80% of patients developed incisional hernia within 1 year of previous surgery and only 3.8% after 2 years in a study. • Most patients in our study 33(82.50%) experienced moderate postoperative pain at 24 hours and during a follow-up period of 3 weeks, pain at the suture site responded to oral NSAID except in 2 cases(5%) where postoperative pain at suture site persisted beyond 3 weeks and subsided by 6 weeks and subsided by 6 weeks with the use of oral paracetamol and diclofenac tablets. • No patients in our study required long acting local aesthetic. • We had 4 patients (10.00%) who developed seroma at the sire of hernial repair which resolved spontaneously within 6-8 weeks. • Wound infection was seen in 1 patient who underwent limited conversion (2.5%) which was managed with local dressings and oral antibiotics. • Fixation of mesh may significantly impact the rate of recurrence. • Recurrence upto 3-4% have been reported in various studies where only tacks were used for mesh fixation.
- 12. Conclusions • Based on our observations we conclude that incorporating few technical modifications in minimally invasive approach for incisional hernia repair like prior defect closure, using larger mesh that covers the whole incision not just the hernial defect, dual fixation of mesh and pre-operative optimisation of risk factors results in reduced incidence and morbidity associated with incisional hernia. • As we have not found any recurrence in our follow up, we believe that the whole incision and not just the hernia must be addressed.