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Sabiston Textbook of

Surgery, 18th Ed

Erik Peltz, D.O.December 9th, 2010

University of Colorado Health Science Center

Department of surgery

Hernias

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Background

Hernia: abnormal protrusion of an organ ortissue through a defect in its surrounding walls.

Reducible: Contents can be replaced

Incarcerated: Cannot

Strangulated: Compromised blood supply

External vs Internal vs Interparietal

Richters hernia

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Background Hernia:

5% of patients will develop an abd wall hernia

75% inguinal region

15 20% incisional 10% umbilical and epigastric

5% femoral

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Background

Groin hernias M:F 25:1 Indirect:Direct 2:1 Femoral F:M 10:1

Umbilical F:M 2:1

Inguinal vs Femoral hernia ?

Inguinal are more common than femoral hernias inboth M, F

10% of females and 50% of males with femoral hernia willdevelop and inguinal hernia

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Background

Indirect Inguinal hernia Which side is morecommon?

More common on right

Slower descent of right teste

Delayed atrophy of the right processus vaginalis

Femoral Hernia

More common of right Tamponade of sigmoid colon protecting Left?

15 20% rate of incarceration. Mandate operative repair when diagnoses

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Anatomy

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Anatomy

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Inguinal Canal

Contains the spermatic cord / round ligament of the uterus

Spermatic cord Cremasteric muscle inferior extension of internal oblique

Testicular artery (aorta), Veins (left renal, right IVC)

Genital branch genitofemoral nerve

Vas deferens Lymphatics

Processus vaginalis

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Bounderies

Inferior Epigastrics Superior Lateral border

Rectus Sheath Medial border

Inguinal Ligament Inferior border

Hesselbachs triangle

direct Hernia

indirect Hernia

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Associated Nerves

Iliohypogastric (L1) suprapubic / inguinal sensation

Beneath the interal obl. at the ASIS

Penetrate I.O. and course superior / medial

Ilioinguinal (L1) Inguinal / scrotal / proximal thigh Beneath the interal obl. At the ASIS

Penetrates I.O. and courses superior / medial overlying cord

Genital branch (L1 L2), genitofemoral

Courses with the cremaster fibers in the spermatic cord

Cremaster motor

Scrotal sensation

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Femoral Canal

Boundaries Iliopubic tract anteriorly

Coopers ligament posteriorly

Femoral vein laterally

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Differential Diagnosis

Inguinal hernia

Femoral hernia

Adenitis

Varicocele

Ectopic teste Lipoma

Hematoma

Sebaceous cyst Hidradenitis

Lymphoma

Metastatic neoplasm

Epididymitis

Testicular torsion

Vascular aneurysm /

Pseudoaneurysm

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Diagnosis

Hx / PE

Supine and Standing

Valsalva

Invagination of scrotum to inspect canal

Inguinal adenopathy? Hx CA?

Rectal Exam? Colonoscopy?

Bulge below inguinal ligament Femoral Hernia Comorbidities: Pulmonary, Cirrhotics, renal failure /

dialysis, Constipation / GI / Colon CA?

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Diagnosis

Imaging: Ultrasound: sensitive and specific

CT

Laparoscopy

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Non-operative management

Fitzgibbons et al., JAMA 2006

700 pts randomizes to non-op vs operative repair

25% non-op pts crossed over (pain / enlargement)

Incarceration with non-op 0.03%

No difference in operative outcome with watchfulwaiting (SSI, OR time, Recurrence Rates)

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Operative management

Tissue Repair High recurrence rates largely replaced by mesh repairs

Remain useful / important in certain situation

Strangulated hernias / bowel resection / infection

Iliopubic Tract Repair

Shouldice Bassini

McVay

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Tissue Repair

Iliopubic Tract Repair Approximates the

transversus abdominis /conjoint tendon to theiliopubic tract.

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Tissue Repair

Bassini Repair Single layer repair

T. Abdominis / IO /conjoint tendon to theinguinal ligament

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Tissue Repair

Shouldice Repair Multi-layer repair

T. Abdominis incised

Overlap T.A. Free edge of T.A. Iliopubic

tract.

2nd deep layer of interal

oblique / T.Abdominis toinguinal ligament

May incorporate relaxingincision

Low recurrence rate fortissue re air 2%

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McVay Tissue Repair

McVay Repair Multi-layer

Very useful in incarcerated or strangulated femoral hernias.

Approximates Transversus Abdominis to Coopers Ligament

(postero-medial aspect of femoral canal)

Relaxing incision in posterior aspect of the anterior rectussheath then allows layered closure of internal oblique to

inguinal ligament tension free fashion.

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McVay Tissue Repair

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Mesh Repair Lichtenstein

Tension is the pricinpal cause of recurrence

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Tension Free Mesh Repair Lichtenstein

Tension is the pricinpal cause of recurrence mesh placed toreinforce the inguinal floor / Internal ring May be sutured to conjoint / internal oblique and iliopubic tract

Results:

Several Randomized Controlled Trials

Recurrence 0% - 3.5%

Critics note short follow-up (1-3 yrs) in many of thesetrials.

Rate is better than 5 15% reported for many primary tissue

repairs.

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Preperitoneal Repair Pre-peritoneal Repair

Involves initial incision 2cm cephalad to the internalring.

Dissection to the preperitoneal plane through the

anterior rectus muscles Both primary and mesh repairs described.

Very useful open approach for:

Recurrent Hernias

Sliding Hernias

Stangulated Hernias

Femoral Hernias

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Laparoscopic Inguinal Repair Trans-abdominal Preperitoneal (TAPP)

Totally Extraperitoneal

Very useful for bilateral hernias / recurrence

Recurrence Rates from RCT 0 10%

Veterans Admin RCT

TEP vs Lichtenstein

Recurrence 10% vs 5% Surgeon experience with technique questioned

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Special Considerations Sliding Hernia

Internal organ comprises a portion of the wall of thehernia sac. (Colon or Bladder)

Careful identification before injury to organ

Recurrent McVay, open preperitoneal, laparoscopic

Stangulated

Open preperitoneal Allows single incision evaluation, resection and

repair of hernia

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Complications SSI

1 2% open, less with laparoscopic

No abx necessary for elective repair

Including placement of mesh

Abx for: ASA > 3, comorbidities, strangulation, etc

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Complications Nerve Injury

Traction, electocautery, transection, entrapment

Ilioinguinal, Iliohypogastric, Genitofemoral

Lateral femoral cutaneous (laparoscopic)

Chronic pain has surpassed recurrence as theleading postop complication (29 76%)

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Complications Ischemic Orchitis

Thrombosis of pampiniform plexus veins

Tender / swollen teste POD 2 5

Continues for 6 12 wks

Test atrophys

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Complications Recurrence:

1 3% tension free and laparoscopic repairs

Most commonly recur within 2 yrs

Shouldice has the lowest reported recurrence rate for tissuerepairs 2%

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Umbilical Hernia Congenital in infants

Most close by 2yoa. Repair if persist after 5yoa.

Adults acquired Obesity, ascites, pregnancy, abdominal distension

Primary Repair vest over pants

10 30% recurrence rate

< 3 cm may primarily repair with interupted suture

> 3 cm mesh under lay, overlay, +/- primary closure

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Epigastric Hernia 2 3 times more common in men

Often incarceration of preperitoneal fat

Pain

20% multiple

80% off of the midline

Repair similar to umbilical hernia

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Surgical Site Infections

Causes and Risk Factors Bacterias Fault (Microorganism)

Surgeons Fault (Local Wound Factors)

Patients Fault (Patient Factors)

BACTERIA LOCAL WOUND PATIENT

Remote site infection Surgical Technique Age

Long-term care facility Hematoma / seroma Immunosuppression

Recent hospitalization Necrosis Steroids

Duration of procedure Sutures Malignancy

Wound class Drains Obesity

ICU Patient Foreign bodies Diabetes / Glucose Control

Previous Abx Malnutrition

Preoperative shaving ComorbiditiesBacterial #, virulence, resistance Transfusions

Cigarette

Oxygen Delivery

Temperature

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Surgical Site Infections

Preventative Measures for SSITiming of action Bacteria Local Patient

Preoperative -Shorten Preop Stay-Antiseptic Shower-Hair Clippers-Postpone Surgery or

treat remote infection-Apporpriate Prophylaxis-Bowel Prep?

-Hair Clippers -Optimize Nutrition-Pre-operative Warming-Strict Glucose Control(80 110)

-Smoking Cessation

Intraoperative -Asepsis-Antisepsis-Control Spillage

-Supplemental O2 (80%)-Intra-operative Warming-Fluid Resuscitation

-Strict Glucose ControlPostoperative -DSG 48 72 hrs

-Early Drain Removal-Avoid Postop Bacteremia

-Early Enteral Nutrition(EAST)-Supplemental O2-Strict Glucose Control-Surveillence Programs

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Bacterias Fault

Asepsis and Antisepsis Practices

Chlorhexidine Shower

No reduction in SSI. Do reduce bacterial colony count. CDC recommendation

Cardiac, Vascular, Prosthetic Procedures

No shave

Germicidal Skin prep

Surgical scrub

Sterile technique

Gowns/masks/hats/gloves/OR FOOT TRAFFIC

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Antimicrobial Prophylaxis

Enteral (Abx bowel prep)

Non-absorbable antibiotics to suppress both aerobicand anaerobic intestinal bacteria.

Neomycin + Erythromycin at 19, 18 and 9 hours before

surgery. (Nichols Prep) Effect of Preoperative Neomycin-Erythromycin Intestinal

Preparation on the Incidence of Infectious ComplicationsFollowing Colon Surgery. Nichols, RL et al. Ann Surg. 1973;178(4): 453-462.

Meta-analyses have recently shown no benefitover IV Abx and when combined with mechanicalprep there is a trend towards increased anastomoticleaks.

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Intravenous

Clean Cases

Not indicated for low-risk, straightforward cleanprocedures with no obvious bacterial contamination orinsertion of a foreign body.

All others: Abx appropriate to anticipated florashould be given within one hour of incision and re-dosed at 1 2 half lives for longer cases.

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Intravenous

No anticipated entry into colon / distal small bowel

Ancef

Clindamycin (cephalosporin allergy)

Potential SB / Colon

Must cover for obligate anaerobic bacteria (Bacteroides)

Cefotetan, Cefoxitin (shorter T )

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Intravenous

Concern for MRSA (IVDA, Institutionalized, NH,recent hospitalization)

Vanc

Patients Allergic to Cephalosporins with plannedbowel surgery

Aminoglycoside or Flouroquinolone + Clinda or Flagyl

Aztreonam + Clinda or Flagyl

Zosyn, Ertapenem, etc

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Common flora

Biliary Tract: Chronic Cholecystitis: < 1% SSI

Gram Negative Gram Positive Anaerobes Fungi

KlebsiellaEscherichia coli

EnterobacterPseudomonasCitrobacterProteus

EnterococcusStreptococcus

BacteroidesClostridium

Candida

Open Chole Lap Chole Open Biliary ERCP

Ancef Low risk NONEHigh risk Ancef

Unasyn,Carbepenems,Cipro +Flagyl,Cefotetan,Cefotaxime,Ceftriaxone

Low risk NoneHigh risk Unasyn,Carbepenems,Cipro +Flagyl,Cefepime

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Common flora

Appendicitis:

Must cover aerobic and anaerobic bacteria Cefoxitin, Cefotetan

Levo + Flagyl

Zosyn ?, Ertapenem ?

Aerobic /FacultativeAnaerobes

Anaerobic

Escherichia coliViridans strepPseudomonasGroup D strepEnterococcus

Bacteroides fragilisBacteroides sppPeptostreptococcusBilophilaLactobacillusFusobacterium

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Common flora

Colon:

Bacteria make up to 90% of the dry weight of feces.

109 Organisms/ml feces

Must cover aerobic and anaerobic bacteria

Cefoxitin, Cefotetan

Levo + Flagyl

Zos n ?, Erta enem ?

Aerobic Anaerobic

Escherichia coliEnterococcusProteusStreptococcus

Pseudomonas

Bacteroides fragilisPeptostreptococcusBilophilaLactobacillus

Fusobacterium

Surgeons Fault

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Surgeons FaultSurgical Technique

Complications happen because you wantthem to happen

Surgical Technique

Careful Tissue Handling

Ensure Adequate Blood Supply

Adequate Hemostasis

Debriedment of Necrotic Tissue

Removal of Foreign Bodies

Monofilament Sutures

Absorbable Sutures

Closed Suction Drains to preventseroma / hematoma

Avoid Open Drains (penrose)

S i l T h i

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Surgical Technique

Wound Closure

Delayed Primary Closure:

Heavily contaminated wounds or wounds withdevitalized tissue.

Allows for the body to develop adequate inflammatory /cellular response to potential pathogens Phagocytic cells progressively increase in number at the wound

edges to a peak at approximately day 5.

Capillary budding

Closure can be accomplished even with high bacterial counts.

Targeting closure ofwound at point of

optimal macrophagenumbers / activity

P ti t F lt

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Patients Fault

Malnutrition

Pre-op TPN / Enteral Feeds

Early post-op Enteral Feeds

Tobacco

Pre / Intra / Post-op Warming

Glucose Control

Adequate resuscitation / CO / O2 deliver?

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Specific Surgical Infections

f l f

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Non-Necrotizing Soft Tissue Infections

Cellulitis: Erythema, Warmth, Induration, Pain

Acute inflammatory response

Small vessel engorgement / stasis

Endothelial leakage / interstitial edema PMN infilitrate

Should resolve with appropriate Abx coverage

Abscess: All of the above +

Sequelae of necrotic tissue, ischemia, pus

Fluctuance

Drainage / debriedment for local control

S f S l f

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Non-Necrotizing Soft Tissue Infections

Abscess:

Head and Neck: S. aureus +/- Strep

Axilla: Gram Negative component

Below Waist: Mixed aerobic and anaerobic gram neg.

S ifi S i l I f i

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Necrotizing Soft Tissue Infections

Absence of clear local boundaries or palpable limit

Layer of necrotic tissue not walled off bysurrounding inflammation

Mortality 16% - 45%

S ifi S i l I f i

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Overlying skin may look remarkably NORMAL

Rapidly progressive infection within the superficial

subcutaneous fascial planes. Bounded by deep investing fascia.

Inflammation / edema / +/- sub-Q air / Tense / Tenderto palpation

Late signs are erythema / ecchymosis / cyanosis /blisters secondary to perforating vessel thrombosis.

S ifi S i l I f i

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Imaging:

CT, MRI: Inflammation (enhances on T2 imaging) /

edema within superficial tissues / Sub-Q gas ?

These modalities are sensitive but non-specific.

High index of suspicion to avoid delay in definitivetherapy Extensive fascial debriedment.

S ifi S i l I f i

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Critical Care Medicine, 2004; 32(7): 1535 1541 Singapore

Retrospective Study

n = 89 pts admitted for Nec. Fasc. n = 225 controls

Employed regression model to evaluate

various laboratory values at admission topredict risk of Necrotizing Fasciitis.

S ifi S i l I f ti

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S ifi S i l I f ti

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Critical Care Medicine, 2004; 32(7): 1535 1541 Singapore

LRINEC Predictive ValueRisk Group LRINEC SCORE PROBABILITY OF NEC.

FASC.PREDICTIVE VALUE

Low Risk LRINEC < 5 50%

Moderate Risk LRINEC 6 7 50% - 75% 6; PPV 92% NPV 96%

High Risk LRINEC 8 >75% 8; PPV 93.4%

S ifi S i l I f ti

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S ifi S i l I f ti

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Finger Test

2 cm incision made down to deep fascia

+ Test Lack of bleeding

Thrombosed vessels

Dishwater exudate

Lack of resistence to finger dissection

Frozen Section

S ifi S i l I f ti

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Necrotizing Soft Tissue Infections require emergentwide excision of all clinically involved tissues.

Re-operation within 24 hours, or sooner Systemic support for impending severe sepsis

Extremity involvement often requires amputation tocontrol local infection.

Abx coverage for common organisms

S ifi S i l I f ti

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Anaya DA et al. Predicting mortality in necrotizing soft tissue infections.

Surg Infect. 2009; 10(6): 517 522

Variable (on admission) # points

Heart rate > 110 1

Temp < 360 C 1

Creatinine > 1.5 mg/dl 1

Age > 50yr 3

WBC > 40 3

Hct > 50 3

Group Categories # Points Mortality Risk

1 0 2 6%2 3 5 24%

3 6 88%

S ifi S i l I f ti

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Intra-abdominal and Retroperitoneal Infections

Mortality: 5 50%

Definitive therapy is NOT antibiotic management,rather Operative or Interventional drainage.

a patient with fever and abdominal pain is notgiven antibiotics without a plan leading tosurgery or other drainage procedure.Administration of antibiotics in this setting beforediagnosis may obscure subsequent findings anddelay diagnosis and will certainly delay definitive

operative management.

S ifi S i l I f tiNon-Surgical Causes of Acute Abdomen

Endocrine and Metabolic Causes

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Endocrine and Metabolic Causes

UremiaDiabetic crisisAddisonian crisisAcute intermittent porphyriaHereditary Mediterranean fever

Hematologic Causes

Sickle cell crisisAcute leukemiaOther blood dyscrasias

Toxins and DrugsLead poisoningOther heavy metal poisoningNarcotic withdrawalBlack widow spider poisoning

Other

PancreatitisPyelonephritisSalpingitisAmebic Liver AbcessEnteritisSPB

Diverticulitis?Cholan itis?

Does the Patient Need a Hole?

-Hx consistent with SurgicalProcess?

-Peritonitis?

-Acidosis?-Shock-Non-op causes excluded

Emergent OperationSource Control

Yes

S ifi S i l I f ti

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-Hx consistent with SurgicalProcess?

-Peritonitis?

-Acidosis?-Shock-Non-op causes excluded

Emergent OperationSource Control

Yes

No-Additional Labs-Imaging-Serial Exam

-Invasive Monitoring-Percutaneous Drainage-Other Intervention (ERCP, PTC,Endoscopy)

Broad SpectrumAntibiotics



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Abx

Cefoxitin, Cefotetan

Timentin

Ertapenem Unasyn

Imipenem

Meropenem

Zosyn Flagyl

Clinda

Vanc

Non Surgical Infections

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Non-Surgical Infections

UTI #1 nosocomial post-op infection

Pneumonia 3rd most common

Central Lines

Sinusitis

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