INCISIONAL HERNIABULGES IN THE BODY WALL COULD MEAN INTERNAL ORGANS ARE OUT OF PLACE, SO PROPERLY PLACE,

CLOSE, HEAL AND PROTECT THE WALL.

Presenting complaint(s)SM [NHN : 52020 2662]Admission Date : 15/02/16 Discharged Date : 19/02/16

SM, 40 y/o i-T/F admitted with Right Iliac Fossa Mass/Collection. She had RIF pain, vomiting, fever and diarrhea. 3rd admission for the same complaint(s). Planned open appendecectomy for clinical appendicitis 5/12 ptca but NO appe. done yet operative diagnosis was RIF abscess thus <50ml of pus drained from the RIF under general anesthesia.

Pathological Sieve – RIF MASS±PAIN

Vascular-AneurysmsInflammatory-Crohn’s disease, Appendicitis,

Diverticulitis, Mesenteric adenitis, PID, TyphilitisTrauma-HematomaAcquired- Incisional Hernia, Colocolic Interssusception

(AIDS), Ectopic kidney, Ectopic pregnancyMetabolic- Hyperlipidemia, HypercortisolemiaInfection- Appendicular/Iliopsoas/Tubo-ovarian

abscess, Ileocecal TBNeoplasm- Appendicular Carcinoid Tumor, Cecum

Tumor, Ovarian Tumor, CRC and non Hodgkin Lymphoma

History of Presenting Complaint(s)

Pt. says firstly she had “sharp-poky-persistent” pain localized in the RIF region then developed fever 3 days p.t.adm. 1 day prior she had (×2) of vomiting and diarrhea (“clear watery” Ø Bile/Blood/Mucus).ROS+(s): ↓ Appetite, ↓ Bowel output and Nausea (×1/7). PV Bleeding (×2/7). -(s): Generalized weakness, constipation, weight loss, pus vaginal discharge, hematuria, urgency, frequency, hesitancy, dysuria, menorrhagia, dysmenorrhea, amenorrhea

History…PMH23/07/15 – 1st AdmissionReferral – Navua Hospital – Dx. Clinical AppendicitisConsented for Open Appendecectomy +/- Exploratory LaparotomySurgical Notes: Under General Anesthesia, Pt. in supine position, Betadine prepared and draped, Lanz was done. Entered peritoneum safely and <50ml of pus drained from RIF. Mass noted (non-differentiable) appendix was plastered to cecum. Drain left in-situ. Closure of fascia with Safil 1/˚ and skin closure with Nylon 2/˚. Post-op care [PARU] and transferred to ASW. [Discharge Date: 28/07/15]20/12/15 – 2nd AdmissionPresented with similar symptoms to the 3rd admission. Dx. Appendicular mass. Abdominal CT showed phlegmon with adhesions to abdominal wall. Tx. with A/Bs. Consented for Colonoscopy- results unremarkable. [Discharge Date: 25/12/15]

History…Allergies – Nil knownDH [as charted] – Cloxacillin 2g IV q6h Gentamycin 200mg IV OD Flagyl 400mg PO q8h Panadol 1g PO q6h Brufen 400mg PO q8h

OB/GYN – P6G6, LNMP: started 2/7 p.t.adm. and currently was having her menses. Regular 2pds/d for 4 days. (-) Contraception

SH – Married, Mother of 6, SDA Lives in Tokatoka Highway, Navua, does D.D and does gardening at home. Husband works at the local supermarket.

Physical FindingsO/E: Middle aged woman, lying in a right lateral position. Pt. appears to be in pain (pt. rates it 6/10)Vitals: Temp: 37.9 BP: 112/82 PR: 89 RR: 20HEENT: Nil(s)- pallor, jaundice, cyanosis. ABDOMEN: Lanz incision scar, Soft tissue mass on RIF ~6×5cm,~5cm Below Umbilicus protrusion, (++) Tender (+) Guarding (-) Rovsing’s sign, (-)distensionResonant percussion, Bowel sounds heard. Cough impulse-pain aggravated

CHEST: Dual HS. Normal S1 and S2. (-)s murmurs, thrills, heaves Bilateral BS clear. (-)s creps, wheezes, stridorEXTREMITIES: Well perfused and warm. CR <2 secs. (-) Edema

Investigative FindingsBloods Done – WCC: 9600 Hgb: 12.6 MCV/PCV: 81/38 Platelet: 234,000, ESR: 30, Creatinine: 59 Albumin: 38

Ultrasonography Done – Mixed echoic mass at RIF over the surgical site [6.3×3.3×5.0cm], AV Uterus measures 9.7×3.6cm, regular outlines and echoes. Endometrium measures 1.1mm.

Computed Tomography Done - Ø

AssessmentLanz Incisional Hernia secondary to:• 5 months post planned appendecectomy + Exploratory Laparotomy incision • Suture technique• ≥ 40 yo• Poor healing

Treatment PlanNon SurgicalPain Relief: IV Morphine 4g PO q4h and Panadol 1g PO q6hFluids: IV Normal Saline 1L q6h,

Antibiotics: IV Antibiotics as charted: Cloxacillin 2g q6h, Gentamycin 200mg OD q8h, Flagyl 400mg PO q8h

SurgicalHernia Repair: Seek consent if agree prep. Pt. NBM for >6hrs before OT. Proper pre-op, intra-op and post-op care. (Monitors: Vitals, O2 sat., Hgb levels, A/B, IDC, pain free)

Operative AssessmentSurgical Operation – Incisional Hernia RepairProcedure – Under Spinal Anesthesia, Pt. vitals stabilized, Pt. in supine position, Betadine prepared and draped over abdomen, Incision through old scar, entered peritoneum safely, identified opened neck of sac, examined contents of sac (ORMENTUM AND CECUM) and was REDUCED. Appendectomy done also. Repaired by mattress stitches of non-absorbable (0/˚ Monofilament Premilene) suture for wound fascia closure. Complete skin closure with absorbable (4/˚ Monofilament Monocryl). Sterile dressing and admitted to PARU.Operative Diagnosis – Cecum Herniation (Cecum-viable)PARU R/V – Post op pain and given IV Morphine, Resp. depression and dizziness and was given O2 Hudson Mask

HERNIAHernia: Abnormal protrusion of a viscus or part of a viscus through an abnormal or weak opening out of the confines of its normal original extremities.Classification(s):[Anatomic Location] – Inguinal, Femoral, Umbilical, Hiatus, Epigastric, Spigellian, Incisional, Obturator, Littre’s, Lumbar[Cause and Severity] – Congenital, Intra-parietal, Internal, Reducible, Irreducible, Incarcerated, Strangulated, Ischemic.Common Classification Used – Reducible or Irreducible with either Incarcerated, Strangulated, Ischemic with respect to its anatomic location. e.g. Irreducible incarcerated Inguinal Hernia

Pathophysiology – Incisional Hernia

• Incisional hernia (EHS)-any abdominal gap with or without a bulge in the area of postop. scar perceptible or palpable by clinical examination or imaging. 12-15% of abdominal surgeries may lead to IH.

Pathophysiology – Incisional Hernia

Risk Factors: Surgical TechniqueType of incision, Suture Material,

Suture Technique

Patient Related Poor wound healing Local infection and seroma

formation >45 yo and M Concomitant disease(s)-Obesity,

Anaemia, Immunosuppression, COPD, Malignancy, DM, AAA

Exogenous toxins-Smoking Hereditary connective tissue

disorder-type III pro-collagen disorder, Ehlers Danlos syndrome

Evidence Based Medicine:IH is most likely associated with -• Vertical/midline incisions Non- synthetic suture e.g. catgut Multifilament sutures Absorbable fascia

closure/sutures Non-Tricsolan coated sutures Incorrect Needle and Insecure

knot Layered closure 1st post operative week-<5%

tensile strength unwounded sutures

<4 suture length/wound length ratio

>10mm or <5mm stitch width No prophylactic mesh Patient related factors

Incisional Hernia RepairSimple Suture

Hernia diameter is <3-4cm Open approach Incision through previous scar Hernia sac dissected sharply from

surrounding tissue of abdominal wall until fascia identified circumferentially.

Debrided fascial edges sutured together with mass closure technique

Non-absorbable monofilament continuous sutures placed ~1cm from fascial edge and 1cm adjacent to the prior suture to avoid tight closure.

Absorbable skin closure with monofilament sutures or staples or adhesive glue (Dermabond)

Advantages Cost effective Less OT time Low rate of infection

Disadvantages Recurrence rate >50% Tension sutures High post operative

pain More seroma formation

Incisional Hernia RepairMesh Placement

Hernia diameter is >4cm Open/Laparoscopic approach Synthetic mesh e.g.

polypropylene, ePTFE Mesh can be placed above fascia

(onlay), below (sublay) or in between fascial edges (inlay). SUBLAY-GOLD STANDARD.

Advantages Low recurrence rate 2-

12% Less seroma formation Low post operative pain Tension free Reinforcement and

reconstructionDisadvantages

High rate of infection Costly More OT time

Summary and ConclusionSummary

IH typically develops after abdominal incisions

Risk factors of IH maybe due to surgical techniques and patient related factors

Treatment of IH can be by open simple suture technique or open/laparoscopic mesh repair

Conclusion Highest Incidence rate of IH

are due to midline incisions Poor suture technique and

wound healing are the major risk factors of IH

Simple suture repair is for <3-4cm hernia diameter and has a higher recurrence rate but a lower risk of infection

Mesh repair is for >4cm hernia diameter and has a lower recurrence rate but a higher risk of infection

THM and RecommendationTake Home Message

IH is best assessed by thorough clinical history, examination and radiological investigation esp. USS and CTS

Synthetic non absorbable, monofilament, continuous fascia closure sutures in simple suture technique is more effective

Sublay (Gold Standard) method in mesh repair is more effective

Laparoscopic approach has minimal complications

Patient related factors such as BMI and smoking is modifiable

Recommendation Decide on giving the most proper,

less invasive and cost effective surgical technique:

Make incisions as short as possible unless long incisions needed otherwise

Close fascia with synthetic, non absorbable, monofilament, continuous suture

Ensure Jenkins SL:WL ratio of 4:1 and <10mm->5mm stitch width

More supply of mesh and should be made affordable

Make the least invasive approach as you can laparoscopically unless open approach is needed otherwise

Close F/U and R/V of pt. on post op Educate patient on Modifiable Risk

Factors such as weight/smoking and emphasize on tappering reduction.

References David C Brooks, MD and John Cone, MD-

UpToDate-Incisional Hernia-Feb 2016 Jason S Mizell, MD FACS-UpToDate-Principles of

Abdominal wound closure-Feb 2016 British Hernia Centre. 1990. British Hernia

Centre. [ONLINE] Available at: https://www.hernia.org/. [Accessed 22 March 16].

European Hernia Society. 1979. European Hernia Society. [ONLINE] Available at:https://www.europeanherniasociety.eu/hernia.html. [Accessed 22 March 16].

“HERNIA” IS A JOURNAL WRITTEN BY SURGEONS WHO HAVE MADE ABDOMINAL WALL SURGERY

THEIR SPECIAL FIELD OF INTEREST. 

GROUPE DE RECHERCHE ET D'ETUDE DE LA PAROI ABDOMINALE (GREPA) 1979, AVICENNE

HOSPITAL IN BOBIGNY, PARIS, FRANCE.PROFS: CHEVERAL, RIVES, STOPPA, HUREAU,

PERISSAT, ALEXANDRE

~Burotukula

ALWAYS THINK FULL HOUSE!