Incisional hernia after liver transplantation

BACKGROUND

Incisional hernia is a potential complication of orthotopic liver transplantation (OLT), with various options for repair.

STUDY DESIGN

We conducted a retrospective review of a series of adult patients with incisional hernias after OLT to identify risk factors and to compare methods of repair.

RESULTS

Incisional hernia repair was performed in 44 of 959 patients (4.6%) who underwent OLT from 1999 to 2005. Mean age at time of OLT was 53 years, and 73% were men. One or more complications of OLT occurred in 33 patients (75%) and included reoperation for bile leak or hemoperitoneum (34%), pulmonary problems (27%), early acute rejection (7%), and severe ascites and retransplantation (5% each). Incisional hernia was diagnosed at 419 days (range 62 to 1,524 days) and repaired at 471 days (range 109 to 1,581 days) after OLT. Presentation included pain or discomfort (78%) and incarceration or strangulation (5%); 17% were asymptomatic. Herniorrhaphy techniques included fascial repair with onlay polypropylene mesh reinforcement (n=25, 57%); fascial repair only (n=15, 34%); or inlay mesh sewn to fascial edges (n=4, 9%). Complications of repair included recurrence in seven patients (16%) and wound infection and seroma in one patient each. Recurrence occurred in five patients with primary repair and two with mesh techniques (33% versus 6%, p=0.04).

CONCLUSIONS

Incisional hernia is a late complication of OLT for which male gender and early post-OLT complications are risk factors. Repair is safe when undertaken after acute problems have resolved and is best accomplished using mesh reinforcement of autologous tissue.

Laparoscopic incisional hernia repair. A new mesh fixation method without stapling

BACKGROUND

Recent advances in laparoscopic surgery have made various abdominal surgeries possible. To avoid wound infection, mesh repair of abdominal incisional hernias is performed laparoscopically. Here we present a new procedure to fix mesh to the abdominal wall.

SURGICAL TECHNIQUE

Four anchoring sutures are made using a suture-grasping device; the additional transabdominal sutures are then made with a modified double-needle device. Additional circumferential fixation with tacks is not necessary.

CONCLUSIONS

This new mesh fixation method involves simple suturing techniques and is less time consuming than the conventional procedure.

Late sigmoid colon internal herniation into the jejuno-jejunostomy mesenteric defect after laparoscopic Roux-en-Y gastric bypass

A 49-year-old female with morbid obesity (BMI 42) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). 10 months after the operation, she presented to the hospital with intermittent mid-abdominal pain. An internal hernia of the sigmoid colon through a mesenteric defect of the jejuno-jejunostomy was found. Although small bowel internal herniation has been widely documented, the finding of large bowel internal herniation has not been previously reported. Maintaining a high index of suspicion and a low threshold for urgent intervention are required when evaluating patients with vague abdominal complaints after LRYGBP.

Laparoscopic Closure of the Petersen Mesenteric Defect

Small-bowel obstruction secondary to internal hernia is a known postoperative complication of laparoscopic Roux-en-Y gastric bypass (RYGBP). Petersen's defect is the most common site of postoperative internal herniation. The authors describe their technique of closure of the infracolic component of the Petersen's defect using continuous non-absorbable suture material. The method has been used successfully to reduce the incidence of internal herniation after laparoscopic RYGBP.

DIEP and pedicled TRAM flaps: a comparison of outcomes

BACKGROUND

Studies comparing similar and sizable numbers of deep inferior epigastric perforator (DIEP) and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions are lacking. The authors hoped to determine whether the DIEP flap has advantages over the pedicled TRAM flap for breast reconstruction.

METHODS

The authors retrospectively reviewed the records of women undergoing breast reconstruction over a 9-year period at a single institution. Patients were grouped by type of reconstruction: DIEP or pedicled TRAM. Only patients with at least 3 months of postoperative follow-up were studied.

RESULTS

A total of 190 women underwent unilateral breast reconstructions (96 DIEP and 94 pedicled TRAM flaps). The patient groups were similar in terms of age, body mass index, preoperative chest wall irradiation and abdominal operations, and cancer stage. The median hospital stay for the DIEP group was shorter than that for the pedicled TRAM group (4 versus 5 days, p < .001). Operative time for the DIEP group (5:53 hours) was longer than that for the pedicled TRAM group (4:46 hours, p < .001). The fat necrosis rates for the pedicled TRAM group were higher (58.5 percent) than those for the DIEP group (17.7 percent, p < .001). Abdominal wall hernias occurred more frequently in pedicled TRAM (16.0 percent) than DIEP patients (1.0 percent, p < .001). Abdominal wall bulge rates were similar for both groups (DIEP 9.4 percent versus pedicled TRAM 14.9 percent).

CONCLUSIONS

DIEP flap reconstruction can be performed with lower morbidity rates and shorter hospital stays than pedicled TRAM reconstruction. Specifically, fat necrosis and abdominal wall hernias are less common in DIEP patients than in pedicled TRAM patients, while flap failure and abdominal wall bulging rates are similar in the two patient groups. These data support the DIEP flap as the preferred option over the pedicled TRAM flap for autologous breast reconstruction in postmastectomy patients.

[Drainage as a rare cause of intestinal incarceration]

Silicone drains are often placed in the abdominal cavity for prophylactic reasons. One complication resulting from drainage includes visceral herniation at the drain site of the abdominal wall defect. An 82-year-old woman underwent a laparotomy for a large pelvic mass. After the operation, she developed small bowel incarceration, which was caused by aggressive drain extraction. Subsequent surgical treatment resulted in the patient's full recovery. This case emphasises the unusual causative mechanism of intestinal obstruction. Drains should be placed carefully in the abdominal cavity in strictly selected cases, only when it is reasonable to do so.

Incisional hernia after a tension-free vaginal tape procedure

A case is presented of an incisional hernia of the inguinal canal presenting 9 months after a tension-free vaginal tape (TVT) procedure and anterior vaginal repair. The TVT and repair procedure was complicated by prolonged postoperative urinary retention requiring midline incision of the tape for resumption of normal voiding. The patient had a hysterectomy several years earlier via a Pfannenstiel incision. No other risk factors for hernia were identified. There are no previous reports of TVT-related incisional hernia. We conclude that incisional hernia is a rare complication of the TVT procedure and that the characteristics of the TVT tape may contribute to late occurrence of herniation.

Gallbladder carcinoma late metastases and incisional hernia at umbilical port site after laparoscopic cholecystectomy

A potentially serious complication of laparoscopic cholecystectomy is the inadvertent dissemination of unsuspected gallbladder carcinoma. There are increasing reports of seeding of tumor at the trocar sites following laparoscopic cholecystectomy in patients with unexpected or inapparent gallbladder carcinoma. Although the mechanism of the abdominal wall recurrence is still unclear, laparoscopic handling of the tumor, perforation of the gallbladder, and extraction of the specimen without an endobag may be risk factors for the spreading of malignant cells. The Authors report the case of late development of umbilical metastasis after laparoscopic cholecystectomy; the presence of an incisional hernia and the finding of a stone in subcutaneous tissue demonstrate the diffusion of tumor cells into subcutaneous tissue during the extraction of gallbladder. The patient underwent an excision of the metastases. She is disease free two years after surgical treatment.

Laparoscopic Repair for Recurrent Abdominal Wall Hernia After TRAM Flap Breast Reconstruction

BACKGROUND

The transverse rectus abdominis musculocutaneous (TRAM) flap is an appealing option for women choosing between various breast reconstructive techniques as it results in an autologous reconstructed breast that is soft and mimics a natural breast. Despite these benefits, there are complications with this procedure, such as pain at the donor site, longer scars, and most frequently the occurrence of abdominal wall hernia or bulge, which has been reported in up to 20%-40% of patients.

METHODS

In this case report, we share our experience with 2 patients who had multiple open hernia repairs, 5 between the 2 of them, after their TRAM flap surgery. Each of these 5 repairs was performed with a Prolene mesh overlay, but not one lasted for more than 6 months. After reviewing our patients' records and our surgical options, we decided to proceed with laparoscopic repair of their recurrent hernias.

RESULTS

The patients are now at postoperative follow-up of 12 months and 15 months, with no evidence of recurrence.

DISCUSSION

Laparoscopic surgery has many benefits, such as shorter hospitalization and decreased pain. For our patients, it also resulted in a more beneficial and longer-lasting repair. We believe that this is partly due to the mechanics of the repair, which allows the abdominal contents to buttress the mesh against the abdominal wall. In addition, we believe that this technique reinforces the posterior sheath, which may not be accomplished in an open repair. This is important as most hernias after TRAM flap surgery occur below the arcuate line. From our experience with these 2 patients, we now advocate the use of laparoscopic repair as a treatment option for those who present with recurrent abdominal wall hernia or bulge after their TRAM flap surgery and believe with more experience it will become a first-line treatment.

High-Frequency Ultrasound: A Useful Tool for Evaluating the Abdominal Wall following Free TRAM and DIEP Flap Surgery

BACKGROUND

This is the first study to use a standardized ultrasound protocol to evaluate hernia and abdominal wall laxity following free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap surgery.

METHODS

All patients who underwent free TRAM and DIEP flap surgery performed by the senior author between the years 1994 and 2003 were recruited for physical examination and ultrasound of the abdominal wall for the dynamic evaluation of hernia and abdominal wall laxity.

RESULTS

A total of 25 of 28 patients were followed up (89 percent). Eleven were in the DIEP flap group (44 percent) and 14 were in the free TRAM flap group (56 percent). Age- and body habitus-matched female volunteers (n = 12) were also used in this study. The mean follow-up was 3.8 years (range, 0.8 to 8.2 years). Although the kappa coefficient was +1 for detection of hernia on physical examination between two independent examiners, the interobserver correlation was poor for detection of bulges (kappa coefficient, +0.53). Ultrasound showed that abdominal wall laxity was statistically highest in the upright position, followed by 30 degrees of truncal flexion, and lowest in the supine position. The amount of abdominal wall laxity detected by ultrasound was significantly higher in the free TRAM flap group than in the free DIEP flap group. Two hernias were detected in the TRAM flap group by ultrasound and one hernia was previously known in the DIEP flap group.

CONCLUSION

This is the first study to establish a standardized ultrasound protocol as an adjunct diagnostic tool to clinical examination for the dynamic evaluation of postoperative hernia and abdominal wall laxity.

Traumatic abdominal hernia and lateral compression type 1 pelvic fracture: a case report

Pelvic fractures often are associated with concomitant injuries. In general, the more severe the pelvic fracture, the more likely other, potentially life-threatening injuries exist. We present a case of a typical type 1 lateral compression pelvic fracture with the less common associated injury of abdominal wall muscle disruption and large-bowel herniation.

Incisional hernia: early complication of abdominal surgery

It has been suggested that early development of the incisional hernia is caused by perioperative factors, such as surgical technique and wound infection. Late development may implicate other factors, such as connective tissue disorders. Our objective was to establish whether incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month). Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed tomography (CT) scan of the abdomen during the first postoperative month were identified retrospectively. The distance between the two rectus abdominis muscles was measured on these CT scans, after which several parameters were calculated to predict incisional hernia development. Hernia development was established clinically through chart review or, if the chart review was inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of incisional hernia patients had a maximum distance of more than 25 mm compared to only 18% (5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may take years. Our results indicate perioperative factors as the main cause of incisional hernias. Therefore, incisional hernia prevention should focus on perioperative factors.

Strangulated hernia through a defect of the broad ligament and mobile cecum: A case report

We report a case of 28-year-old woman presenting with small bowel obstruction. She had neither prior surgery nor delivery. An upright abdominal radiograph revealed several air-fluid levels in the small bowel in the midabdomen and the pelvic cavity. Computed tomography demonstrated a dilated small bowel loop in the Douglas’s fossa, but no definite diagnosis could be made. Supportive therapy with draining the intestinal fluid by a long intestinal tube did not result in improvement, which suggested the possibility of a strangulated hernia. Exploratory laparotomy revealed mobile cecum and a 20-cm length of the ileum herniated into a defect of the right broad ligament. As a gangrenous change was recognized in the incarcerated bowel, its resection was carried out, followed by end-to-end anastomosis and closure of the defects of the broad ligament. The postoperative course was uneventful. Intestinal obstruction is a very common cause for presentation to an emergency department, while internal hernia is a rare cause of obstruction. Among internal hernias, those through defects of the broad ligament are extremely rare. Defects of the broad ligament can be either congenital or secondary to surgery, pelvic inflammatory disease, and delivery trauma. In conclusion, we emphasize that hernia of the broad ligament should be added to the list of differential diagnosis for female patients presenting with an intestinal obstruction. Early diagnosis and surgical repair reduce morbidity and mortality from strangulation.

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases

BACKGROUND

It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects.

METHODS

Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects.

RESULTS

Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure.

CONCLUSIONS

AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.

Operative Standardisierung bei randomisiert kontrollierten Studien in der Chirurgie

BACKGROUND

INSECT is an internationally registered, three-armed, multicentre, intraoperatively randomised model trial of the Study Centre of the German Surgical Society. The interventions being compared are running suture technique with slowly absorbable monofilament suture material (PDS vs MonoPlus) and interrupted technique with a braided, rapidly absorbable suture material (Vicryl). The primary endpoint is the rate of incisional hernias 1 year postoperatively.

MATERIAL AND METHODS

A total of 25 surgeons from 24 different institutions at all levels of care evaluated the theoretical and practical sessions of the surgical investigator meeting using 25 criteria, including course organisation, content, and speaker evaluation, and a categorical grading system from 1 (very good) to 6 (insufficient).

RESULTS

Distribution of the 625 grades was: very good (1) n=367, good (2) n=207, satisfactory (3) n=39, adequate (4) n=2, and "No statement" n=10. The average score for the investigator meeting was 1.5.

CONCLUSION

The participants felt they were successfully prepared theoretically and practically for trial interventions and conduct by attending the meeting. Clear explanation of the measures for treatment equivalence before and during trials is mandatory in randomised controlled surgical trials.

It is highly unlikely that the development of an abdominal wall hernia can be attributable to a single strenuous event

INTRODUCTION

There is a commonly held belief that the development of a hernia can be attributed to a single strenuous or traumatic event. Hence, many litigants are successful in compensation claims, causing mounting financial burdens on employers, the courts, insurance companies and the tax-payer. However, there is very little scientific evidence to support this assertion. The aim of this study was to ascertain whether there was any causal link in this process.

PATIENTS AND METHODS

A total of 133 new patients with 135 abdominal herniae of all varieties (115 inguinal, 3 femoral, 9 umbilical, 4 incisional, and 4 ventral or epigastric), of which 25 were recurrent received structured questionnaires on arrival in the surgical clinic. These questionnaires covered all possible aetiological factors for hernia development (type of work, COAD, smoking, pregnancy, obesity, chronic bladder outflow obstruction, previous surgery including appendicectomy), in addition to any possible attribution to a single strenuous or traumatic event. We then reviewed the GP records in the surgery of all patients who answered positively to the latter possible cause.

RESULTS

In the study group, 119 (89%) reported a gradual onset of symptoms. Of the 15 (12 male, 3 female; 11%) who believed that their hernia might be related to a single strenuous or traumatic event, 5 had no other aetiological factors. However, not one of the 15 was found to have contemporaneous forensic medical evidence to support their possible claim.

CONCLUSIONS

We conclude that we are unable to find any clinical evidence to support the hypothesis that a hernia might develop as the result of one single strenuous or traumatic event. While we accept that this mechanism might still possibly occur, we believe that, at best, it is extremely uncommon. If a medical expert is preparing a report on such a case in a claim for personal injury, then they have a duty to the court to examine carefully all the contemporaneous medical records. If no clinical evidence exists to support the claim, then they have a duty to the court not to support the plaintiff's claim.

Prevalence and management of hernias in peritoneal dialysis patients

OBJECTIVES

The aim of this study was to assess the prevalence of hernias before and after the start of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal disease, and to evaluate the result of a proposed surgical treatment.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENTS

122 patients who started CAPD from 1994 to 2000; 26 hernias were diagnosed in 21 (17.2%) patients.

MAIN OUTCOME MEASURES

Finding of hernias; morbidity associated with catheter insertion and hernia repair; recurrence of hernias.

RESULTS

19 hernias were detected in 15 patients (12.3%) before they began CAPD; only 7 hernias were observed while on CAPD. Umbilical (61.5%) and inguinal (26.9%) hernias were the most common. Multiple hernias were detected in 4 patients. Simultaneous repair of hernia and catheter insertion was performed in patients with pre-existing hernias. Under local anesthesia, most patients were operated on with surgical techniques of tension-free hernioplasty using a polypropylene mesh. Only mild post-operative complications were recorded: 3 seromas and 1 hematoma. No fluid leakage was found in our series. There were no long-term complications (infection or recurrence) related to the mesh.

CONCLUSIONS

73% of hernias in peritoneal dialysis patients occur before starting dialysis. Hernia problems in these high-risk patients can be safely solved using a careful technique with application of tension-free hernioplasty. Most may be repaired under local anesthesia with simultaneous catheter insertion.

Clinical Evaluation of Fibrin Glue in the Prevention of Anastomotic Leak and Internal Hernia after Laparoscopic Gastric Bypass: Preliminary Results of a Prospective, Randomized Multicenter Trial

BACKGROUND

Gastro-jejunal anastomotic leak and internal hernia can be life-threatening complications of laparoscopic Roux-en-Y gastric bypass (LRYGBP), ranging from 0.1-4.3% and from 0.8-4.5% respectively. The safety and efficacy of a fibrin glue (Tissucol) was assessed when placed around the anastomoses and over the mesenteric openings for prevention of anastomotic leaks and internal hernias after LRYGBP.

METHODS

A prospective, randomized, multicenter, clinical trial commenced in January 2004. Patients with BMI 40-59 kg/m2, aged 21-60 years, undergoing LRYGBP, were randomized into: 1) study group (fibrin glue applied on the gastro-jejunal and jejuno-jejunal anastomoses and the mesenteric openings); 2) control group (no fibrin glue, but suture of the mesenteric openings). 322 patients, 161 for each arm, will be enrolled for an estimated period of 24 months. Sex, age, operative time, time to postoperative oral diet and hospital stay, early and late complications rates are evaluated. An interim evaluation was conducted after 15 months.

RESULTS

To April 2005, 204 patients were randomized: 111 in the control group (mean age 39.0+/-11.6 years, BMI 46.4 +/- 8.2) and 93 in the fibrin glue group (mean age 42.9+/-11.7 years, BMI 46.9+/-6.4). There was no mortality or conversion in both groups; no differences in operative time and postoperative hospital stay were recorded. Time to postoperative oral diet was shorter for the fibrin glue group (P = 0.0044). Neither leaks nor internal hernias have occurred in the fibrin glue group. The incidence of leaks (2 cases, 1.8%) and the overall reoperation rate were higher in the control group (P=0.0165).

CONCLUSION

The preliminary results suggest that Tissucol application has no adverse effects, is not time-consuming, and may be effective in preventing leaks and internal hernias in morbidly obese patients undergoing LRYGBP.