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CASE PRESENTATION AND SHARING OF INFORMATION ON INCISIONAL HERNIA

CASE PRESENTATION AND SHARING OF INFORMATION ON INCISIONAL HERNIA. by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center. R.C, 58/M TONDO, MANILA. CHIEF COMPLAINT : BULGING ABDOMINAL MASS. HISTORY OF PRESENT ILLNESS:. 2 yrs PTA  Px underwent ‘E’

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CASE PRESENTATION AND SHARING OF INFORMATION ON INCISIONAL HERNIA

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  1. CASE PRESENTATION AND SHARING OF INFORMATION ON INCISIONAL HERNIA by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center

  2. R.C, 58/M TONDO, MANILA

  3. CHIEF COMPLAINT: BULGING ABDOMINAL MASS

  4. HISTORY OF PRESENT ILLNESS: • 2 yrs PTA  Px underwent ‘E’ Exploratory Laparotomy, duodenorrhapy, omental patching for a Perforated PUD.

  5. HISTORY OF PRESENT ILLNESS: • 22 months PTA noted bulging abdominal mass, about the size of the patient’s fist, most noticeable during straining or prolonged standing and reduced spontaneously when the patient assumed a recumbent position. (-) episode of vomiting (-) changes in BM

  6. HISTORY OF PRESENT ILLNESS: • Gradual increase in the size of the abdominal mass prompted consultation and subsequent admission at the OMMC

  7. PAST MEDICAL Hx: • s/p ‘E’ Ex-Lap, duodenorrhaphy, omental patch for Perforated Peptic Ulcer Disease – OMMC – July 2004 • No Hypertension • No DM • FAMILY Hx: No heredofamilial disease noted

  8. PERSONAL/SOCIAL Hx: smoker, 20 pack-years, stopped last 2004 occasional alcoholic beverage drinker

  9. PHYSICAL EXAMINATION: BP= 120/80 CR=89 RR= 20 T=36.5 HEENT: pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPC C/L: SCE, no retractions, clear BS HEART: adynamic precordium, NRRR, no murmur

  10. ABDOMEN: Flabby, NABS, soft, non-tender (+) healed midline incision (+) mass, soft, non-tender, reducible, around the umbilicus with fascial defect approx 8 x 8 cms around the umbilicus (+) mass, soft, non-tender, reducible, 6 cms above the umbilicus with fascial defect approx 2x2 cms.

  11. EXTREMITIES: full equal pulses, No edema

  12. SALIENT FEATURES: • 58 y/o, M • 2-yr History of bulging abdominal mass, reducible • Fascial defect approx 8 x 8 cms and 2 x 2 cms • History of previous operation

  13. On and off bulge at the level of the abdominal wall

  14. On and off bulge at the level of the abdominal wall Abdominal wall hernia

  15. On and off bulge at the level of the abdominal wall Abdominal wall hernia History of operation; bulge at incisional site

  16. On and off bulge at the level of the abdominal wall Abdominal wall hernia History of operation; bulge at incisional site Incisional hernia

  17. On and off bulge at the level of the abdominal wall Abdominal wall hernia History of operation; bulge at incisional site Incisional hernia Not reducible reducible

  18. On and off bulge at the level of the abdominal wall Abdominal wall hernia History of operation; bulge at incisional site Incisional hernia Not reducible reducible Defect on 1 site Defect on 2 or more sites

  19. On and off bulge at the level of the abdominal wall Abdominal wall hernia History of operation; bulge at incisional site Incisional hernia Not reducible reducible Defect on 1 site Defect on 2 or more sites strangulated Not strangulated

  20. Clinical Diagnosis:

  21. BASIS: Patient with history of : on and off bulging mass on incision site, s/p ‘E’ Exploratory Laparotomy without any vomiting or BM changes

  22. Do I need a para-clinical diagnostic procedure? NO

  23. Pretreatment Diagnosis

  24. TREATMENT • PRETREATMENT DIAGNOSIS: Incisional Hernia without obstruction or gangrene s/p ‘E’ Ex-Lap – July 2004

  25. TREATMENT • GOALS OF TREATMENT: - reduce hernial content - repair the fascial defect - prevent recurrence of incisional hernia after the repair

  26. TREATMENT OPTIONS

  27. TREATMENT OPTIONS

  28. TREATMENT OPTIONS

  29. TREATMENT OPTIONS

  30. TREATMENT OF CHOICE SUBLAY PROSTHESIS REPAIR

  31. PREOPERATIVE PREPARATION • Informed consent • Psychosocial support • Optimize patient’s health • Screen for any condition that will interfere with treatment • Prepare materials

  32. OPERATIVE TECHNIQUE • Patient supine under CLEA • Asepsis/Antisepsis • Sterile drapes • Excision of scarred incision skin • Subfascial flap dissection separating rectus from peritoneum/hernial sac • Hernial sac opened

  33. OPERATIVE TECHNIQUE cont.. • Inspection of intraabdominal organs for gut adhesions and additional fascial defects • Silk suture laid on peritoneum for mesh anchoring • Interrupted Silk 2-0 sutures approximating small superior fascial defect • Excess peritoneum trimmed • Closure of peritoneum with chromic 3-0 simple continuous

  34. OPERATIVE TECHNIQUE cont.. • Mesh laid over the area of larger defect • Anchoring sutures tied • Closure of fascia with simple continuous suture, Vicryl-0 • Hemostasis • Running continuous with Vicryl 2-0 subcutaneous • Subcuticular Vicryl 4-0 • Correct sponge, instrument and needle count • Dry Sterile Dressing

  35. OPERATIVE TECHNIQUE

  36. OPERATIVE FINDINGS • 7 cms fascial defect from umbilicus down and 1 cm above • Small fascial defect approx 1x1 cms, 6 cms superior to the umbilicus, left of the midline • No incarcerated bowel noted

  37. OPERATION DONE: Incisional Herniorrhaphy with subfascial prosthesis

  38. POST-OP CARE • Sufficient analgesia • Nutrition • Wound care • Monitoring of complications and treat as indicated • Advice on home care of wound

  39. POST-OP CARE • Advice on ff-up plans • Avoid straining • Avoid lifting heavy objects/ learn the proper mechanics of lifting • High fiber diet • Quit smoking • Maintain a healthy weight

  40. SHARING OF INFORMATION

  41. INCISIONAL HERNIA • occur as a complication of previous surgery • Causes: 1. poor surgical technique 2. rough handling of tissues 3. use of rapidly degraded absorbable suture materials 4. closure of the abdomen under tension, 5. infection

  42. 6. Male sex 7. advanced age 8. morbid obesity 9.abdominal distention 10. cigarette smoking 11. pulmonary disease 12. hypoalbuminemia

  43. The incidence of incisional hernia was significantly lower when nonabsorbable sutures were used in a continuous closure; however,

  44. the incidence of suture sinus formation (9%) and that of wound pain were significantly higher

  45. The best definition: any abdominal wall gap, with or without a bulge, that is perceptible on clinical examination or imaging by 1 year after the index operation.

  46. Incidence: 3 – 20% (double if the index operation is associated with infection)

  47. Risk: midline - 10.5% transverse - 7.5%, paramedian - 2.5%

  48. Early evisceration is commonly seen among males.

  49. Incarceration and strangulation occur with significant frequency, and recurrence rates after operative repair approach 50%.

  50. Classification of incisional hernias I. According to localization (modified Chevrel) • Vertical • 1.1. Midline above or below umbilicus • 1.2. Midline including umbilicus right or left • 1.3. Paramedian right or left • Transversal • 2.1. Above or below umbilicus right or left • 2.2. Crossed midline or not

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