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Current trends in the management of hernias
Dr Jaja, P T Surgical Resident, Surgery Team F, BMSH 25/11/2016
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Objectives Introduce and review the definition of a hernia Review the Aetiopathogenesis of hernias Present the relevant anatomy Management options for hernias Trends in Hernia repair Materials Trends in Hernia repair Techniques Complications of current management Give a concluding statement
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Introduction and Definition
Hernia: Greek ‘Hernios’; Bud or Shoot Hernias; abnormal protrusion of viscera from their containing cavity. Commonest indication for elective surgery (greater than 500,000 annually in the US).
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Basic Aetiopathogenesis of hernias
Generally, a hernia occurs from either: A defect or weakness in the cavity wall Defects (dysgenetic or anatomical) Weakness (ageing, frequent/multiple pregnancies, obesity, infection) Persistently increased intra-cavitary pressure ( chronic cough, ascitis,)
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Relevant Anatomy
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Management options Dependent on Options Type of hernia
Size of hernia neck / Cavity wall defect Stage of the hernia General morbidity of patient Availability of skills and materials Options Herniotomy Herniorhaphy Hernioplasty (mesh repair, component seperation)
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Trends in Hernia repair materials
Primitive treatments Reducible hernia: Bandages and Girdles Strangulated hernia: Rest, cold water, purgation, diet Trusses were noted in Egyptian sarcophaguses Ancient Greeks used gold wire sutures and silver strand filigrees (as prosthesis) Theodore Billroth; 1857 envisioned current practice with prostheses Burke; 1940: Tantalum metal sheet prosthesis
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Main materials PP, PTFE, ePTFE, POL, Vicryl, Dacron
Nylon; first plastic used as suture and later woven into nylon mesh (albeit, it lost strength over time, required explantation if infected) Main materials PP, PTFE, ePTFE, POL, Vicryl, Dacron Characteristics of proposed mesh in 1959 Non-metallic Synthetic Non-absorbable Resistant to infection
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Theoretical support for mesh repair
Identification of fascial weakness as being from collagen deficiency Due to failure in hydroxylation of lysine and proline Hence, Hernial defect reinforcement became the order of the day.
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Mesh Weight: Heavy (100g/cm2)or Light weight(33g/cm2)
Pore size: For infiltration of Macrophages, Fibroblasts, Angiogenesis Micro-porous allows bacteria but not macrophages Pathophysiology Suture Fixation Inflammation with infiltration by macrophages and blood vessels Mesh incorporation and/or degradation
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Composite meshes These combine more than one material
Require specific orientation Visceral: micro-porous to prevent adhesions Non-visceral: macro-porous; permit tissue ingrowth Three basic materials (PP, POL, ePTFE)
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Bioprosthesis Uses Issues here include Hybrid meshes
Pedicled or free fascia (eg Fascia lata) Decellularized grafts from human, porcine and bovine tissue; leaving just a collagen matrix. Composition: Dermal, Pericardial or Submucosal Processing: Stripping or Cross-linking Uses Grossly contaminated hernias Burst abdomen Issues here include Biocompatibility Immunogenic potential Foreign body response (usually less) Hybrid meshes
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Trends in Hernia techniques
Prior rudimentary hernia repairs had been executed 19th Century breakthrough in Anaesthesia and Aspesis /Antisepsis (especially mid 19th century) More robust surgeries were now done
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Inguinal hernia repairs
Bassini; Posterior wall reinforcement Halsted; Modified Bassini’s repair Shouldice; 1940 Four layer suturing Lichtenstein; 1989 Tension-free (anterior mesh) Nyhus; Posterior-open-mesh Davis & Arregui 2003 Laparoscopic repairs TAPP (transabdominal preperitoneal repair) TEP(total extraperitoneal repair)
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Tension-free techniques
Halsted’s Tension free technique 1892 Tanner’s Slide (sliding part of rectus sheath lateral and downwards to inguinal ligament) Kirschner’s pedicled or free fascia used for closure (inlay as described by Gallie) Narath; 1896 used Silver Filigree Moloney nylon darning Usher; 1958 First Polypropylene mesh Lichtenstein consolidated on this technique
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Ramirez et al; 1990 Component separation
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Complications of current management
Laparoscopy : GA Longer surgery duration Higher chance of intra-peritoneal tissue damage Risk of post-operative adhesions Mesh related: Seroma formation Granuloma formation Mesh dislocation Mesh infection Mesh encapsulation (with stiff scar formation) Loss of elasticity and shrinkage
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Fate of a hernia Reducibility Obstruction Incarceration Strangulation
Visceral necrosis / Ischemia
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Conclusion The Management of hernias has markedly evolved.
Availability of skills and materials is a considerable factor militating against the use of these novel techniques. The novelity in the techniques have also not come without a price of novel complications.
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Case I Mrs BI 63 years old multipara
10 year Hx of recurrent painful peri-umbilical swelling, initially intermittent, recently constant Obese abdomen, 15cm panus in longest diameter, two anterior abd wall defects (8 and 2cm) Diagnosis of Supraumbilical hernia Had Mesh repair of Supraumbilical hernia
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Case II Mrs AA 32 year old primipara
2 months Hx of recurrent painful peri-umbilical swelling, Obese abdomen, 5cm panus in longest diameter, 2cm anterior abd wall defect just superior to umbilicus Initial diagnosis : Supraumbilical hernia intraop. diagnosis: Paraumbilical hernia Had Suture repair of supraumbilical hernia
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Case III Mr DI esq. 42 year old Legal practitioner
5 years Hx of recurrent epigastric pain; with occasional self-limiting, hard, painful epigastric swelling Obese abdomen, 4cm panus in longest diameter, 2cm anterior abd wall defect Diagnosis: Epigastric hernia Had Suture repair of Epigastric hernia
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Case IV Mrs UI 50 year old post-menopausal, primipara
8/12 Hx of feacal matter draining from a left inguinal region wound. Prior hx of left mid-inguinal swelling of 4/12 (drained pus and then feacal matter), intermittent lower abd pains 1x1cm left mid-inguinal sinus, draining feacal matter Initial diagnosis : Enterocutaneous fistula ? cause intraop. diagnosis: Richter’s type left petit hernia Had omental plugging of left petit hernia
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Bibliography FitzGerald, JF; Kumar, AS. Biologic versus Synthetic Mesh Reinforcement: What are the pros and cons? Clinics in Colon and Rectal Surgery. 2014; 27(4): Heller, L; McNichols, CH; Ramirez, OM. Component Separations. Seminars in Plastic Surgery. 2012; 26(1): 25-28 Bilsel, Y; Abci I. The search for ideal hernia repair; mesh materials and types. International Journal of Surgery. 2012; 10: Holzheimer, RG. Inguinal Hernia: Classification, Diagnosis and Treatment; Classic, Traumatic and Sportsman’s Hernia. European Journal of Medical Research. 2005; 10: Hee, RV. History of Inguinal Hernia repair. Jurnalul de Chirurgie, Iaşi, 2011, Vol. 7, Nr. 3 [ISSN 1584 – 9341]
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