Management of Ventral Hernias hernia-js.pdf · Physical Exam – All vitals WNL ... GI tract...

Management of Ventral Hernias

Jason Sulkowski MD

www.downstatesurgery.org

Case • xx y F with epigastric hernia presented with pain over

hernia & NBNB emesis

• PMH: C-section

• Meds: None

• Allergies: NKDA

• Social: Denies toxic habits

• Physical Exam – All vitals WNL – Abdomen: 4cm round, firm, nontender,

nonreducible hernia cephalad to umbilicus; otherwise soft, NT ND, C-section scar

• Labs:

– BMP: 135/3.9 94/28 19/0.8 <130 – Lactate: 1.8 – CBC: 19.5> 15.6/46.4 <284

• Imaging – CT A/P: ventral hernia with partial small

bowel obstruction, pelvic free fluid

OR Course • Midline incision over hernia • Dissection carried to hernia sac

– Sac was isolated, opened • Ischemic omentum and bowel within sac • Sac resected, edges of hernia defect freed from adhesions

– Defect size 2cm wide x 4cm long • Ischemic omentum resected • After ~15 min waiting, small bowel did not improve • Resection of 20cm mid-jejunum with primary anastomosis

– Side to side functional end to end • Fascia closed primarily with running loop PDS

– No mesh

Post-Op Course • POD 1

– Extubated in PACU

• POD 2 – + Flatus – NGT, foley removed

• POD 3

– Diet started

• POD 4 – Discharged home

Questions? www.downstatesurgery.org

Management of Ventral Hernias www.downstatesurgery.org

Ventral Hernias

• Incisional

• Umbilical

• Epigastric

• 150,000 ventral hernia repairs annually – No reduction despite increased MIS

Incisional Hernias • 10-15% of all surgical incisions will

herniate

• 90% of incisional hernias are midline ex-laps

• Risk factors1:

– Surgical site infection • Superficial • Deep

– BMI >25kg/m2

– Stitch length

1Jensen KK et al., Surg Endosc. 2016; 30(10): 4469-79.

Umbilical Hernias • Congenital weakness in abdominal

wall at site of umbilical vessels

• Increased intra-abdominal pressure can cause defect to worsen in adulthood

• Important to identify prior to any

abdominal incision so it can be incorporated and repaired

Epigastric Hernias • Diastasis recti

– Weakness between R & L rectus muscles

– Can be visualized with contraction of rectus muscles (inclining and reclining)

• Not during valsalva

• Epigastric hernia is true defect

• Important to identify prior to any abdominal incision so it can be incorporated and repaired

Diagnosis & Management

• Elective

• Urgent / Emergent

Reducible Hernia

• History

• Physical Exam

• Imaging

Reducible Hernia Repair Indications • Expanding hernia

• Loss of domain

• Cosmesis

• Thinning of tissue over hernia

• Patient request

Incarcerated / Strangulated Hernia

• History

• Physical Exam

• Imaging

Incarcerated / Strangulated Hernia Repair Indications

• All must be fixed urgently or emergently

• Stabilize, resuscitate patient first !

Classification System for Ventral Hernias

• European Hernia Society

• Ventral Hernia Working Group

• Hernia Patient Wound (HPW) System

European Hernia Society

Description SSO Rate Recurrence Rate

Stage 1 <10 cm; Clean wound 10% 10%

Stage 2 <10 cm; Contaminated 10-20 cm; Clean 20% 15%

Stage 3 >10 cm; Contaminated Any >20 cm 40% 25%

Sabiston Textbook of Surgery, 20th Ed.

Ventral Hernia Working Group Description Recommendations

Grade 1 Low complication risk; No wound infection history Repair as per surgeon preference

Grade 2 Co-morbid conditions (e.g. smoker, obese, DM2, immunosuppressed)

Increased SSO risk; Potential advantage for biologic reinforcement

Grade 3 Prior wound infection; Stoma present; GI tract violation

Permanent synthetic repair not recommended; Potential advantage for biologic reinforcement

Grade 4 Infected mesh Septic dehiscence Biologic repair material should be used

Montgomery A. Hernia. 2013; 17: 3-11.

Hernia Patient Wound (HPW) System

Petro CC & Novitsky YW. Hernia Surgery. 2016.

• Like TNM system for cancer

• Hernia – H1: <10 cm – H2: 10-20 cm – H3: >20 cm

• Patient

– P0: no comorbidities – P1: at least 1

• Wound

– W0: clean – W1: contaminated

Prevention www.downstatesurgery.org

Bite Size • STITCH Trial

– “Small bites versus large bites for closure of abdominal midline incisions: a double-blind, multicentre, randomised controlled trial”

– SBVLBFCOAMI ?!

• Prospective, multicenter, double-blind RCT – Post-op follow-up clinician and patient blinded

• Included: >18 years, undergoing elective abdominal surgery via

midline wound

• Excluded: prior midline incision within 3 months, pregnant, involved in other study

Deerenberg EB et al., Lancet. 2015; 386: 1254-60.

• Large bites group: N = 248 – 1cm bites every 1cm – PDS 1 Loop with 48mm needle

• Small bites group: N = 276 – 5mm bites every 5mm – PDS 2-0 with 31mm needle

• Technique:

– 2 sutures placed from either end of incision – Overlap in middle by 2cm – Tied separately

• Primary outcome: incisional hernia detected by clinical

exam OR imaging

• Hernia recurrence at 1 year (p = 0.022): – Large bites: 21% – Small bites: 13%

• Weaknesses:

– Use of imaging to detect hernias likely increased rates in both groups

– Use of different stitches in each group

Interrupted vs Continuous • INSECT Trial

– “Interrupted or continuous slowly absorbable sutures – Evaluation of abdominal closure techniques”

• Prospective, multicenter, RCT • Included: >18 years, undergoing elective abdominal

surgery via midline wound expected to be >15 cm

• Excluded: emergency procedure, recent chemoTx or radioTx

Seiler CM et al., Ann Surg. 2009; 249 (4): 576-82.

• Interrupted Vicryl: N = 152 • Continuous Monoplus: N = 162 • Continuous PDS: N = 158

• Primary outcome: incisional hernia detected by

ultrasound

• Hernia recurrence at 1 year (p = 0.087): – Interrupted Vicryl: 15.9% – Continuous Monoplus: 12.5% – Continuous PDS: 8.4%

• Conclusion:

– Trend towards improved outcomes with continuous closure technique

– Rates are still high and new techniques are needed

Prophylactic Mesh – “Prevention of incisional hernias by prophylactic mesh-augmented

reinforcement of midline laparotomies for AAA treatment”

• Prospective, multicenter, RCT • Included: undergoing elective AAA repair via midline

incision

• Excluded: emergency procedure, prior incisional hernia repair or mesh placement

Muysoms FE et al., Ann Surg. 2016; 263 (4): 638-45.

• Non-mesh: N = 58 – Fascia closed with continuous PDS suture

• Mesh: N = 56 – Ultrapro mesh (polypropylene) placed retromuscular – Fascia closed with continuous PDS suture

• Primary outcome: incisional hernia detected by

clinical exam OR imaging

• Hernia recurrence at 2 years (p < 0.0001): – Non-mesh: 28% – Mesh: 0%

• No adverse effects related to mesh placement

• Conclusion:

– Significant reduction in incisional hernias with mesh placement

– Dissemination of these techniques for all surgeons

Treatment Approaches www.downstatesurgery.org

Ventral Hernia Repair Approaches • Tension Repairs

– Primary tissue-to-tissue – Inlay mesh – Abdominal wall

reconstruction – Reconstruction plus mesh

• Tension-Free Repairs

– Sublay – Onlay

• Laparoscopic or Open

Rives-Stoppa Repair

• Considered Gold Standard for midline ventral hernias

• Sublay mesh repair

• Principles:

– Separate posterior sheath from rectus muscle – Close peritoneum – Place mesh pre-peritoneal and retromuscular – Close linea alba over mesh – Mesh is isolated from peritoneum and

subcutaneous tissue

Hernia Repair Battles

• Tissue (or Suture or Primary) vs Mesh Repair

• Laparoscopic vs Open Repair

• Which mesh is the best?

Hernia Repair Battles

• Tissue (or Suture or Primary) vs Mesh Repair

• Laparoscopic vs Open Repair

• Which mesh is the best … for my patient?

Tissue Repair vs Mesh - Incisional • Multicenter RCT

• Included: patients with incisional hernia <6 cm long

• Excluded: infection, multiple hernias

• Tissue repair: N = 97

– Polypropylene sutures 1 cm apart • Mesh repair: N = 84

– Polypropylene mesh, underlay with 2-4 cm overlap – Covered with peritoneum or Vicryl mesh

Luijendijk RW et al., N Engl J Med. 2000; 343: 392-8.

• Primary outcome: hernia recurrence by exam OR ultrasound

• Hernia recurrence within 3 years (p = 0.005)

– Tissue repair: 46% – Mesh repair: 23%

• Risk factors for recurrence:

– Mesh repair: 0.4 (0.2, 0.8) – Infection: 4.3 (1.5, 12.6) – Previous surgery for AAA: 3.8 (1.7, 8.5)

Luijendijk RW et al., N Engl J Med. 2000; 343: 392-8.

• Additional long term follow up: – Tissue repair: 75 months – Mesh repair: 81 months

• Hernia recurrence (p < 0.001)

– Tissue repair: 63% – Mesh repair: 32%

• Complications (mesh repair):

– Sinus tract from mesh: 5% – Enterocutaneous fistula: 3%

Burger JWA et al., Ann Surg. 2004; 240(4): 578-85.

Tissue Repair vs Mesh – Umbilical/Epigastric

• Meta-analysis

• Included: 9 studies comparing elective suture and mesh repair of primary ventral hernias

• Combined totals: – Suture repair: N = 1145 – Mesh repair: N = 637

Nguyen MT et al., JAMA Surg. 2014; 149 (5): 415-21.

• Pooled hernia recurrence rates (p < 0.001): – Non-mesh: 8.2% – Mesh: 2.7% – Odds ratio: 0.31 (0.18, 0.52)

• Multivariate analysis

– Recurrence associated with suture repair

– Seroma (3.8% vs 7.7%) and SSI (6.6% vs 7.3%) associated with mesh repair

Nguyen MT et al., JAMA Surg. 2014; 149 (5): 415-21.

Mesh Repair – Incarcerated • Prospective cohort study

• 80 patients with incarcerated or strangulated ventral hernias repaired with onlay polypropylene mesh

• Bowel resection in 18 (22.5%) • Peri-operative mortality 2 (2.5%)

• Mean follow up: 50 months

Bessa SS et al., Hernia. 2013; 17 (1): 59-65.

• Recurrence rate: 1.3%

• Complications: – SSI: 11.3% – Seroma: 6.3% – PNA: 5% – DVT: 1.3% – Mesh infection: 1.3%

• Use of mesh is safe for incarcerated hernias +/- bowel

resection

Bessa SS et al., Hernia. 2013; 17 (1): 59-65.

Biosynthetic Mesh Repair – Contaminated

• COBRA Study – “Complex open bioabsorbable reconstruction of the abdominal wall.”

• Prospective cohort study

• Included: ventral hernia with clean-contaminated or contaminated wound, closed single piece of GORE BIO-A mesh

• Excluded: clean or dirty wounds, significant comorbidities

Rosen MJ et al., Ann Surg. 2015; Epub.

• N = 104, 24 months follow up

• Recurrence: 17% – More likely with intraperitoneal mesh placement (40% vs 13%, p = 0.045)

• Wound infection: 18%

– Superficial: 9% – Deep incision: 10% – Organ space: 2%

• Other complications: – Fistula: 2% – Bowel obstruction: 2% – Wound dehiscence: 1%

Rosen MJ et al., Ann Surg. 2015; Epub.

Summary: Tissue vs Mesh Repair • Mesh repair associated with lower recurrence than tissue repair

for: – Incisional hernias – Umbilical and epigastric hernias – Incarcerated hernias and contaminated fields

• Mesh repair associated with increased complications – Still relatively uncommon

Laparoscopic Repair

• First described in 1992 – Now being used with increasing frequency

• Principles:

– Safe entry into abdomen – usually NOT the umbilicus – Ports placed lateral enough to allow 3-5 cm overlap of

mesh – Perform careful adhesiolysis and reduction of hernia – Measure defect size – Insert and attach the mesh

• Tacks ok if mesh will have tissue ingrowth • Sutures recommended if mesh will have minimal tissue ingrowth

Open vs Laparoscopic Repair • Meta-analysis

• 12 prospective RCTs comparing open vs laparoscopic incisional hernia repairs

• Increase in bowel complications for laparoscopic repair – OR: 2.56 (1.15, 5.72)

Awaiz A et al., Hernia. 2015; 19 (3): 449-63.

• Open and laparoscopic repairs similar for: – Operative time – Overall complications – Wound infections – Hematoma / seroma – Time to PO intake – Length of stay – Back to work – Recurrence rate

Awaiz A et al., Hernia. 2015; 19 (3): 449-63.

Open vs Laparoscopic Repair • Cochrane Systematic Review

• 10 prospective RCTs comparing open vs laparoscopic ventral hernia repairs

• Increase in bowel complications for laparoscopic repair – OR: 2.33 (0.53, 10.35)

• Decrease in SSI for laparoscopic repair

– RR: 0.26 (0.15, 0.46)

Sauerland S et al., Cochrane Database Syst Rev. 2011; 16 (3).

• Open and laparoscopic repairs similar for: – Recurrence rates

• Data too heterogeneous to make conclusions about:

– Operative time – Length of stay – Pain

Sauerland S et al., Cochrane Database Syst Rev. 2011; 16 (3).

Abdominal Wall Reconstruction • More complex defects require more

complex repairs

• Many (many) different techniques

• Mesh still used in many cases – Overlay mesh to provide extra strength – Inlay mesh to bridge a gap in fascia edges

Component Separation • First described by Ramirez et al. in 1990

• Technique:

– Create subcutaneous flap laterally – Relaxing incision 2 cm lateral to linea

semilunaris – Blunt dissection between external and

internal oblique muscles

Ramirez OM et al., Plast Reconstr Surg. 1990; 86 (3): 519-26.

Transversus Abdominis Release • First described by Novitsky et al. in

• Technique: – Incise posterior rectus sheath near midline – Dissect sheath away from rectus muscle – Junction of anterior and posterior sheath is

incised at linea semilunaris – Tranversalis fascia is dissected away from

transversus abdominis

Novitsky YW et al., Am J Surg. 2012; 204 (5): 709-16.

Conclusions • Common

• All shapes and sizes

• Mesh repairs associated with lower recurrence – Safe to use for incarcerated / strangulated hernia with bowel resection – Safe to use for contaminated fields

• No definitive benefit to laparoscopic repairs

• Nearly as many types of repairs as types of hernias

Conclusions • Adapt your repair technique to each unique hernia defect

Questions? www.downstatesurgery.org

Questions!

Risk factors for development of an incisional hernia include all of the following EXCEPT: • A. Smoking • B. BMI <30 • C. Malnutrition • D. Steroids • E. Wound infection

Questions!

Risk factors for development of an incisional hernia include all of the following EXCEPT: • A. Smoking • B. BMI <30 • C. Malnutrition • D. Steroids • E. Wound infection

Questions!

Which of the following is NOT true with regard to incisional ventral hernias? • A. Primary repairs are associated with 30-50% recurrence. • B. The incidence of incisional hernias after laparotomy is ~10%. • C. All types of mesh can be safely placed in the intra-abdominal

cavity. • D. Prosthetic mesh repairs have reduced the recurrence to <10%. • E. Comorbidities such as DM2, HTN, and obesity, and common in

patients with incisional hernias.

Questions!

Which of the following is NOT true with regard to incisional ventral hernias? • A. Primary repairs are associated with 30-50% recurrence. • B. The incidence of incisional hernias after laparotomy is ~10%. • C. All types of mesh can be safely placed in the intra-abdominal

cavity. • D. Prosthetic mesh repairs have reduced the recurrence to <10%. • E. Comorbidities such as DM2, HTN, and obesity, and common in

patients with incisional hernias.

Management of Ventral Hernias hernia-js.pdf · Physical Exam – All vitals WNL ... GI tract...

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