VENTRAL HERNIA REPAIR BY

DR NIKHIL AMEERCHETTY MS GENERAL SURGERY RESIDENT

email : nikhilameerchetty@gmail.com

Introduction Protrusion Through The Anterior Abdominal Wall Fascia.

1. Spontaneous 2. Acquired

Incisional Hernias Account For 15% To 20% Of All Abdominal Wall Hernias 4 Million Laparotomies Performed Annually 2% To 30% Incidence Of Incisional Hernia, 150,000 Ventral Hernia Repairs Are Performed Each Year.

Rucinski J, Closure of the abdominal midline fascia,Am Surg 67:421–426, 2001.

ANATOMY

Treatment: Operative Repair

Primary repair – recurrence rate of 10 – 50%

Mesh repair - recurrence rate of 5-25%

Wright BE, , Is laparoscopic hernia repair Am J Surg 184:505–508 Anthony T, Factors affecting recurrence , World J Surg 24:95–100, 2000.

Choice of operation ?????

COMPONENT SEPARATION TECHNIQUE

Types

Open CST Laproscopic CST Endoscopic with open/laproscopic CST Anterior CST Posterior CST All the above with or without mesh reinforcement

TECHNIQUE OF COMPONENT SEPERATION TECHNIQUE

D

Abdominal Wall Reconstruction Utilizing the Component SeparationTechnique: Does Reinforcing Mesh Reduce Recurrences?

J Scott Roth*, Dennis F Diaz, Margaret Plymale and Daniel L DavenportDepartment of Surgery, University of Kentucky College of Medicine, Lexington, USA

Introduction Incisional hernia Incidence 11-20% in patients undergoing laparotomy Primary suture based repair - high incidence of recurrence. Mesh for hernia repair improved recurrence rates . Laparoscopic hernia repairs not suited for 1. Loss Of Abdominal Domain,2. Infection 3. Abdominal Contamination.

Mudge M, Hughes (1985) Incisional hernia: a 10 year prospective study Br J Surg 72: 70-71. Cengiz Y, Israelsson LA (1998) Incisional Hernia 2:175-177.

The Component Separation Technique (CST)

Ramirez and co-workers in 1990

Abdominal wall without the need for a synthetic mesh.

Autologous Tissue Transfer

Approximation Of The Rectus Abdominis Muscle Complex

Closure Of The Linea Alba Following Bilateral Release Of The External Oblique Aponeurosis And Posterior Rectus Sheath.

Methods Institutional Review Board approval

surgical database at the University of Kentucky 2004 - 2009.

Chi square test, Fisher’s exact test, or ANOVA .

Operative Reports Reviewed

Biologic Or Synthetic Mesh .

Demographic Data

Complications (Wound Infection, Wound Necrosis, Abscess, Seroma , Cellulitis)

Recurrences. ( Physical Examination Or Abdominal CT Scan) .

Results

Total of 126 patients Median follow-up 15.6 months (1-36 month range).

The overall recurrence rate was 20.6%.

Wound complications were seen in 46%

25.5 16.7 27.3

46.0 20.6

Conclusions Wound complications following CST are increased in patients with

obesity.

Hernia recurrence rates are similar between primary, recurrent, and multiply recurrent hernia repairs

Reinforcing CST hernia repairs with either biologic or synthetic mesh has no proven advantage over an unreinforced repair.

WC, van den Tol MP, de Lange DC, Braaksma MM, et al.(2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343: 392-398.

Introduction

Very large incisional hernias defect of more than 10 cm .

The OCS gives an abdominal wall release of 10–15 cm on every side

Endoscopic component separation

The ECS can be combined with other open or laparoscopic procedures

In 2007, Rosen et al.

Retrospective study of seven patients

The residual defect size 338 cm2 . ECS enabled tension-free primary fascial reapproximation in all

patients.

Technique of ECS A bilateral 15-mm skin incision below the costal margin

10-mm balloon dilator is inserted.

Blunt dissection between the external and internal oblique muscle.

Fascia of the external oblique muscle is vertically incised

Results

There was one superficial surgical site infection

No recurrences were identified.

STUDY

Harth and colleagues Retrospective study 32 ECS to 22 OCS.

PARAMETRE ECS OCS

major wound morbidity (p=0.07)

19 % 41 %

recurrences rates (p=0.99) 27% 32%

Hospital length of stay (p=0.09)

8 11

STUDY

Bilateral ECS combined with an open sublay repair in 23 patients

Defect size of 210 cm2 .

The abdominal wall release on each side was 2–6 cm.

All patients received large-pore PP mesh.

Follow up 21 months

Complications

Hematoma 3

Lateral abdominal wall bulging 3

Superficial wound infection 1

StatementsLevel 3

The ECS is feasible with low morbidity The ECS can be combined with lap IPOM, open IPOM, open sublay, and open onlay

technique in complex hernias Abdominal wall release after ECS is less extensive than after OCS There are fewer wound infections and wound healing problems after ECS compared

to OCS

Level 4

The question whether the lateral compartment should be augmented with mesh remains unresolved.

Recommendations

Grade C In large and very large ventral and incisional hernias, the ECS

can be considered in combination with open or laparoscopic mesh techniques if the surgeon is able

Methods

Medical records at Royal Liverpool Hospital from 2009 to 2012 were reviewed.

Patients were classified by the Ventral Hernia Working Group (VHWG) grading system.

Grade 1Low risk

Grade 2Comorbid

Grade 3 Potentially contaminated

Grade 4 Infected

No H/O wound infection Smoker Stoma present Infected mesh Obese Previous wound

infection Septic dihiscence

Diabetic Violation of gastrointestinal tract

Immunosuppressed

Results Twenty-three patients’ (15 males, 8 females) .

Median age 57 years (range20-76 years).

Median follow-up at the time of review was 17 months (range 2-48 months).

There were 13 grade III hernias and 10 grade IV hernias

Wound infection (13%), superficial wound dehiscence (22%), seroma formation (22%) and stoma complications(9%).

Hernias have recurred in 3 patients (13%).

Conclusions

Components separation and reinforcement with biological mesh is a successful technique in the grade III and IV abdomen with acceptable rate of recurrence and complications.

Patients and methods

2006 and 2010,

Medical records analysed

Nine patients underwent the combination procedure.

Mean size of the transverse defect was 20 cm .

Conclusion

Low recurrence rate in the short-term follow-up.

Increased occurrence of postoperative wound infections.

Methods

75 patients over a 10-year period (2000 to 2010)

Adult patients (aged 18 to 75 years at the time of operation)

Results

62% of recurrent hernias diagnosed within the first year

86% after a 2-year follow-up.

28% of recurrences were detected within 6 months

Hawn MT, Long-term follow-up . J Am Coll Surg 2010;210:

Conclusions

Literature review CST without mesh shows low recurrence rates - underestimated

Author experience - high recurrence rate if follow up is more than a year

Mesh augmentation will decrease recurrences,

Methods A single institutional retrospective review

42 patients ECS at a single institution by a single surgeon for ventral hernia repair with prosthesis from 2010 to 2013.

17 patients open ventral hernia repair (OHR)

25 laparoscopic ventral hernia repair (LHR).

Conclusions ECS with laparoscopic fascial re-approximation had

Shorter operative time

Estimated blood loss

Wound complications similar in both groups

Increase hernia recurrences post-operatively in the laparoscopic group.

Thank you