Ventral Hernias Flashcards
Risk factors for incisional hernia
- Patient factor
- Obesity
- Smoking
- Malnutrition
- Immunosuppressive therapy
- Connective tissue disorder
- Technical factor
- Wound infection
- Subopitmal fascia closure
- Abdominal fascia dehiscence
- Type of abdominal surgery
Anatomical classification of incisional hernia
(European Hernia Society)
- Medial zone (to lateral margin of rectus sheath)
- Subxiphoid
- Epigastric
- Umbilical
- Infraumbilical
- Suprapubic
- Lateral zone
- Subcostal
- Flank
- Iliac
- Lumbar
Management options for ventral hernia
- Observation
- Surgery
- Approach
- Open repair
- Laparoscopic repair
- Robotic repair
- Reconstruction
- Primary repair
- Mesh placement
- Approach
How to decide the management for incisional hernia repair
- Disease factor
- Symptomatic?
- Asymptomatic ->patient decision
- Symptomatic
- Risk of strangulation -> emergency
- Hernia defect size
- Anatomically difficult positions? (suprapubic, subxiphoid, lateral)
- Symptomatic?
- Patient factor
- Patient preference
- Contraindications to surgery (fitness for GA/pneumoperitoneum)
- Major comorbidites
- Compromised pulmonary condition
- Large hernai defect
- Previous surgeries
Laparoscopic vs Open ventral repair
- Laparoscopic:
- multiple RCTS and meta-analysis
- Ex. 2014 systemic review (World J Surg), 2017 meta-analysis (Hernia)
- lower surgical site + mesh infection
- Less pain
- Fast recovery
- Comparable long term durability (similar recurrence)
- Open had shorter operative time for umbilical and paraumbilical hernias**
- higher risk fo wound infection
- higher risk of wound dehiscence
- Conclusion
- Laparoscopic: high risk for wound complications, hernia <10cm, off midline hernia
- Open: low risk for wound complication, low risk hernias, complex ventral hernias with large defect/loss of domain/contamination
Robotic vs Laparoscopic
- Two RCTs (BMJ 2020) comparing surgical outcomes
*
Component Separation Technique
- Surgical technique to treat complex hernias
- Aims to restore abdominal wall integrity by transposition of autologus tissue
- Steps:
- Dissection of subcutaneous fat from anterior rectus sheath and EOA
- Longitudinal release of EOA lateral to rectus abdominis muscle
- Separation fo EOM and IOM up to mid-axillary line
- mobilisation fo posterior rectus sehath for additional medial advancement of rectus abdominis
Types of mesh
- Synthetic (polypropylene, polyester, PTFE)
- Biologic (bovine, porcine, equine)
- Biosynthetic (long acting synthetically derived resorbable mesh 6-36 months)
Spigelian hernia
Hernia through teh spigelian fascia (Aponeurotic portion between the Semilunar line and the lateral edge of rectus muscle)
An intraparietal hernia (herniates transverse abdominis and internal oblique muscle)
Surgery is indicated because of high risk of incarceration.
Lumbar region boundaries
Superior: 12th rib
Inferior:Iliac crest
Medial: Erector Spinae Muscle
Lateral: External oblique muscle
Grynfeltt Triangle
Superior lumbar region
- Boundaries
- 12th rib
- lateral edge of quadratus luborum
- posterior margin of internal oblique
Petit triangle
Inferior lumbar triangle
- Boundaries:
- iliac crest
- lateral free edge of latissimus dorsi
- posterior margin of external oblique
Surgical options for lumbar hernia repair
- Open anterior approach
- Laparoscopic
- Transperitoneal most popular
- Total extra-peritoneal
Obturator canal boundaries and contents
Superior aspect of the obturator foramen that connects the pelvic to medial compartment of the thigh
Boundaries: obturator membrane (inferiomedial) and pubic rami (superiorlateral)
Contents: obturator artery, vein, nerve
Characteristics of obturator hernia
- Elderly female (female broader pelvis and wider obturator canal)
- Right side more common then left (sigmoid tends to prevents left side)
- Classic symptom: groin pain radiating down to medial thigh
*
Howship Romberg sign
- Inner thigh pain excerbated by extension, adduction and internal roatation of thigh (compression of obturator nerve by hernia sac)
- Present in ~50% of patients only
Hannington Kiff sign
loss of the thigh adductor reflex in the presence of a positive patellar reflex
It is caused by obturator nerve compression leading to adductor muscle weakness.
Surgical approaches to repair obturator hernia
- Transperitoneal/Abdominal (open/laparoscopic)
- Preperitoneal (open/laparosopic)
If reduction of obturator hernia requires incision of obturator membrane, how would you approach?
done at the lower margin of the obturator canal downward and medially avoiding injury to the nerve and blood vessels positioned just lateral to the sac
