Presentation on theme: "Brandon H. Kilgore, MD, FACS"— Presentation transcript:
1 Brandon H. Kilgore, MD, FACS Hernia surgeryBrandon H. Kilgore, MD, FACS
2 DefinitionA defect or hole allowing contents of one cavity to pass into another cavity or potential spaceMost commonly, this hole occurs in the fibromuscular tissues comprising the abdominal wallThis is an anatomic problem requiring surgery for definitive treatment.
4 Causes of Hernia Relative ‘weakness’ of tissue Openings or previous openings in the abdominal wall (or canal where a structure perforates the wall)Groin: spermatic cord or femoral vesselsUmbilicus: umbilical cordAny incision: scar is weak relative to native tissueAny activity that increases intra-abdominal pressure - thereby increasing abdominal wall tension - may contribute to development of hernia signs or symptomsHeavy lifting, coughing, straining, strenuous activity
5 SymptomsBulgeMay be obscured in obese individualsNatural history: enlarge over timePainUsually caused by stretching of the hernia ringImproved by ‘reduction’ of the hernia ‘contents’Worse in evening, after upright, after strainingDiagnosis: description of symptoms, physical exam (sometimes imaging)
6 Complications Incarceration Obstruction Strangulation Hernia contents get stuck – and cannot be reducedRequires EXPEDITED surgeryObstructionWhen bowel is extruded through a hernia and becomes so tight that food cannot pass through that segmentCauses severe pain, nausea, vomitingRequires URGENT surgeryStrangulationWhen hernia contents – especially bowel – become stuck so tightly that adequate blood flow cannot reach these contentsCauses necrosis (death) of the strangulated contentsEventually results in perforation, peritonitis, sepsis, and deathRequires EMERGENT surgery
7 Indications for Surgery / Timing Complications of herniaPotentially incapacitating or life-threateningSymptoms of herniaLifestyle- and productivity-limitingPresence of herniaPotential for development of complicationsGreatest potential: new, small, femoral, recurrent, scrotalOtherwise difficult to predict who will experience complications 3mo, 2y; hernia-related adverse events / patient-year)Potential for development of symptomsAsymptomatic groin hernias may be followed, but a quarter to a third become symptomatic within 2-4 years.Impaired perception of health or ?decreased productivity
8 Principles of Inguinal Surgery Tension = RecurrenceSuture repair = TensionForces are concentrated at the suture lineMesh = minimal tension standard of careDistributes tension over the surface area of the meshLess pain than suture repairProsthetic (woven plastic lattice) mesh: more durableAllows ingrowth of tissue (incorporates into the tissue)Less dependent upon tissue healing for successFew exceptions: contamination, small umbilical hernia
9 Types of Inguinal Hernia Surgery Open (anterior)Single incision directly overlying the abnormal anatomyDissection is distant from bowel and vasculatureMesh is sutured anterior to the fasciaRecurrence rates are thought to be lower (<5%)Improved durability may be preferable for manual laborersPain may be greater up to 2 weeksLaparoscopic (posterior)Multiple incisions distant from anatomyPotential for incisional hernia in addition to recurrenceMesh is tacked posterior to fasciaPotential for rare but serious complicationsRecurrence rates are thought to be higher (up to 10%)Pain may be less in first 2 weeksPossible earlier return to work for sedentary workers (~1 day)
10 Principles of Ventral Hernia Surgery Reconstruction of normal anatomyReduce or excise hernia contentsExcise hernia sacExcise scarReapproximate native tissues under minimal tensionMay require component separationMesh reinforcementPosterior prosthetic meshAnterior biological meshMeticulous wound closureExcise redundant tissue
11 Types of Surgery for Ventral Hernia UmbilicalSuture repair if smallFascial closure over mesh ‘patch’?laparoscopicIncisionalLaparoscopyUnable to reestablish native anatomyHole remains, but excluded from abdomenPossible seroma formationLess pain & decreased length of recoveryOpenCombined suture closure and(?dual) mesh reinforcementGreater potential for wound complicationsLonger in-hospital and at-home recovery
12 Surgical Consultation Surgery will not be at the time of initial visitInitial visit will include history, examination, discussion of options, and explanation of risks.Request that patients bring the following:List of previous medical conditions and surgical interventionsList of current medications and allergiesIf pt has had previous surgery for hernia, please bring operative reports.
13 Outpatient Surgery Logistics Preoperative prohibitionsEating or drinking after midnightAspirin, plavix, coumadin, pradaxa, etc.SmokingTimingAdmitting & pre-op prep: ~1.5 hoursSurgery: hoursRecovery Room: 1-2 hoursOutpatient Surgery Recovery: 2-6 hoursPostoperative checklistPain and nausea controlTolerate liquidsAmbulatoryUrinateRide home
14 Surgical Risks Medical risks of anesthesia & surgical stress Heart attack, stroke, kidney failure, blood clot, pneumonia, abnormal heart rhythmInfection & wound complicationsBleedingMesh complicationsRecurrenceNerve injury(numbness & chronic pain)Urinary retentionRisks of intra-abdominal surgeryBowel, bladder, vascular injury, etc.
15 Early Post-Operative Expectations No driving for 2-3 days or while on narcoticsSwelling, bruising, and soreness are commonKeep wound clean & dry for 2 days – no immersion for >1 weekGenerally plan to avoid travel for 1 weekDiet is as tolerated but prudence is advisedExpect increased rest requirementsAmbulate multiple times a dayEnsure adequate bowel function
16 Pain & Return to Work Varies widely between people and procedures Return to Work dependent upon:Type of procedure (open incisional v. umbilical)Patient comorbidities (age, obesity, debilitation, etc.)Availability of ‘light duty’ for 4-8 weeksLaparoscopy & Umbilical herniaPain should be much improved after 1 weekReturn to work when stamina & pain allow (~1wk)Open Inguinal HerniaPain may last 2 days to 2 weeksReturn to work within 2 weeks given pain & staminaWC patients may experience greater time off work over those with commercial insurance (34 days vs. 13 days)
17 Rationale for activity restrictions Tensile strengthThe tendency of the wound to resist disruptionNative, intact tissue > operated tissue / scarIncreases with wound remodeling and collagen depositionProportional to timeNears eventual strength at approximately 6 weeksHealing is slowed by tobacco use, diabetes, steroid administration, etc.Need tensile strength to increase prior to activities which would disrupt the repair:Heavy lifting & coughing > moderate lifting, bending, straining > jogging, walking