or The call you don t want at 2:00 a.m.* *Or even at 8:00 a.m. Michael G. Sarr, MD Professor of Surgery Mayo Clinic South Canada
WEST CANADA EAST CANADA
Clinical talk Hernias Inguinal Umbilical Incisional The Emergency Hernia Post laparoscopy Outine And incisional hernias in the morbidly obese
Incarceration The Emergency Hernia General Concepts Chronic: Non-emergent - unless SBO Acute: Emergent Strangulation: Emergent - but plan the approach
Inguinal hernia Acutely Incarcerated 1 st question: Is it an inguinal or femoral hernia? Male vs female Neonate vs young vs older Landmarks 2 nd question: Duration of incarceration? 3 rd question: Strangulation? ALL ARE IMPORTANT
Acutely Incarcerated Inguinal Hernia Short duration: no signs of strangulation or SBO Conservative initial approach Supine Relaxation Pain medicine Then try to reduce hernia Consider observation if any persistent pain Early semi-elective herniorrhaphy* *In our practice, that day or next day
Acutely Incarcerated Inguinal Hernia Lots of pain, longer duration incarceration SBO Can t exclude strangulation Emergent operation (no long resuscitation)* Which incision? Groin vs pre-peritoneal approach Proponents of each approach Laparoscopic? (Not me!) *As for perforated ulcer/diverticulitis, etc.
Acutely Incarcerated Inguinal Hernia- Inguinal Approach Pros n More familiar anatomy n Can repair hernia with autogenous tissue (McVay vs Shouldice) n Only 1 site of potential future hernia Cons n Exposure not as good for Femoral hernia Bowel resection Will need to ligate inferior epigastric vessels and transect posterior inguinal floor* *Unless you are lucky
Acutely Incarcerated Inguinal Hernia Pre-peritoneal Approach Pros n Much wider exposure to bowel n Much better visualization of femoral hernia n If no strangulation, I think a better repair (prosthetic-based) n If femoral hernia, no need to transect posterior inguinal floor Cons n Less familiar anatomy n If strangulated, more difficult repair l Bioprosthetic l Separate incision for autogenous repair n Tough exposure in OBESE patients
Pre-peritoneal Approach Anterior superior iliac spine Incision Not a midline incision! Internal ring
Acutely Incarcerated Inguinal Hernia Laparoscopic Approach I don t suggest this Pros n None Cons n Risk of bowel injury n Difficult bowel resection
Acutely Incarcerated Inguinal Hernia My Approach If no strangulation inguinal approach If strangulation or SBO pre-peritoneal approach
Permanent Prosthetic vs Biologic vs Tissue Repair No strangulation permanent prosthetic Strangulation depends on approach Inguinal tissue repair Pre-peritoneal - biologic
Umbilical Hernia Incarceration/ Strangulation Similar approach to inguinal hernia Timing of incarceration Signs of strangulation/sbo Operative approach: open If really obese, likely omentum (pre-peritoneal fat) If acute, try to reduce Repair No strangulation permanent prosthetic sublay Strangulation 1 autogenous repair (biologic prosthetic if necessary) Expect recurrence
Incisional Hernia Acute incarceration almost all will need exploration Can t count on omentum plugging hole Hard borders/prior sutures Worry about small Swiss cheese defects* SBO in a larger incarcerated hernia may be adhesions *From an interrupted closure
Acutely Incarcerated Incisional Hernia Approach Laparoscopic vs Open? Depends on Suspicion of strangulation Suspicion of fat, incarceration, not bowel Surgeon expertise Prior history of abdominal surgery
Incarcerated Incisional Hernia - 1 No strangulation Permanent prosthetic-based repair, not autogenous repair* Debate over best technique of incisional herniorrhaphy** *Unless really worried about bowel **I m a sublay fan - retrorectus
Incarcerated Incisional Hernia - 2 Strangulated 1 st reaction - DAMN! 2 nd reaction type of repair Obviously no permanent prosthetic All will recur DON T BURN ANY BRIDGES No components separation Technique of temporary repair Best option: 1 autogenous repair Other options: - Biologic prosthetic $$$ - Absorbable mesh
61-yo male with ascites, child B/C cirrhotic (Hepatitis C) and a symptomatic 5-cm umbilical hernia Best treatment is: 1) Nonoperative, medical management 2) Refer to liver transplant service 3) TIPS 4) Peritoneo-venous shunt (Denver shunt) 5) Elective repair
61-yo male with ascites, child B/C cirrhotic (Hepatitis C) and a symptomatic 5-cm umbilical hernia, but with very thin erythematous ulcerated skin Best treatment is: 1) Intense nonoperative medical management 2) Emergent TIPS 3) Emergent peritoneo-venous shunt 4) Operative repair with intraperitoneal drains
The Emergent Hernia Ascites and Umbilical Hernias (UH) 20% of patients with refractory ascites have an UH Possible complications Symptoms Ulceration (2 to pressure) Rupture (rare) Incarceration Worries about operative repair Ascites leak Infection Hepatic decompensation
The Emergent Hernia Ascites and Umbilical Hernias (UH) Medical management vs elective repair* Multiple series overall complications with operation Types of repair: prosthetic superior to 1 repair Co-management TIPS Peritoneo-venous shunt Peritoneal catheters Rarely liver transplant Laparoscopic repair? - Elective *Trianos, AM J Med Sci 2011 review article
Weeping Umbilical Hernia in Cirrhotic Best treatment is prevention intense medical treatment Usually not incarcerated/strangulated Aggressive medical management Diuretics takes days Pericentesis Even consider peritoneo-venous shunt (Denver type) or TIPS Early repair
Cirrhotic Umbilical Hernia Needs Emergent Operation BAD KARMA REAL BAD KARMA High mortality prepare patient and family Operation Goals watertight closure If no strangulation/contamination Composite wide sublay (eptfe with overlying mesh) If strangulation/contamination Primary closure with thick biologic sublay Not absorbable mesh Leave peritoneal catheter
Post-Laparoscopy SBO after laparoscopy THINK Port site hernia! BUT, MORE IMPORTANTLY Internal hernia! Internal hernia! Internal hernia! Internal hernia!
Bariatric Surgical Complications Intestinal Obstruction-Other Than Adhesions
What Do You Do For This Patient? Male or female Age: 30-70 Large midline abdominal wall hernia (>12x20 cm)* S/P multiple repairs or S/P colectomy, sigmoid diverticulitis/hartmann s procedures, THA/BSO, AAA repair, open Nissen, etc! AND (of course) Ht: 5 8 i.e. BMI > 35 Wt: >300 lb *Big hernia; note > 12x20 cm!
Ventral Hernia in Morbidly Obese Patient Should bariatric surgery be considered in these patients? 1) Yes 2) No
Ventral Hernia in Morbidly Obese Patient Should bariatric surgery be done 1) Before ventral herniorrhaphy 2) At time of ventral herniorrhaphy 3) After ventral herniorrhaphy 4) Not at all
Bariatric Surgery in AWR Staged AWR-Bariatric Surgery First In theory, MAKES THE MOST SENSE! Healthier patient (benefits of weight loss-comorbidities) Less risk occurrence Easier Better AWR Combine with abdominoplasty BUT NOT ALL AGREE VARIES WITH PATIENT DESIRES VARIES WITH SIZE OF HERNIA VARIES WITH OPERATIVE TECHNIQUE Open vs lap RYGB vs band/sleeve
Bariatric Surgery in AWR Question 1 DOES MORBID OBESITY PREDISPOSE TO RECURRENCE AFTER AWR?
Bariatric Surgery in AWR AWR in Patients with Morbid Obesity SUMMARY Recurrence rate is increased (~10%) Laparoscopic repair is best Appropriate if patient refuses bariatric surgery BUT-this speaker s opinion (bias) is that: These patients benefit by bariatric surgery ( comorbidities) Subsequent hernia repair better/easier Better overall management The huge hernias are BEST treated by bariatric surgery 1 st
Bariatric Surgery in AWR AWR at Time of Bariatric Surgery - 1 Pros 1 operation/1 anesthetic 1 convalescence Already intraperitoneal Prevents future SBO if herniated content requires reduction for bariatric procedure Older age patients Cons Clean-contaminated procedure (? alloplastic prosthesis) Known risk hernia postop Hernia patching, no AWR Wound infection (open) More difficult operation Will need separate abdominoplasty
Bariatric Surgery in AWR Staged AWR Bariatric Procedure First Considerations Size of hernia Risk of SBO before AWR Hernia may increase in size/complexity* Need for abdominoplasty More adhesions BUT AFTER WEIGHT LOSS Easier repair Can add components separation Healthier patient Less chance recurrence Adequate skin coverage Combined with abdominoplasty Timing of AWR *Esp if open procedure required!
Bariatric Surgery First Open How to deal with the abdominal wall defect? Considerations Just close skin/sac WORRY OF EVISCERATION Absorbable mesh hernia recurs at 3 months (and then gets bigger!) Bioprosthesis expensive but may allow greater weight loss before hernia occurs NO ONE EXPECTS A PERMANENT REPAIR DO THEY?
Bariatric Surgery in AWR Summary of Presentation Recurrence of hernia after AWR is in morbid obesity Complications of AWR are increased in morbid obesity, (esp as an open procedure) Lap AWR does not medialize rectus muscles Recurrence after primary repair of hernias in morbid obesity approaches 100% Risk of SBO is increased when bariatric surgery performed first and herniated contents are reduced No consensus on bariatric surgery 1 st Simultaneous Staged procedure (bariatric AWR)