[The ways of improving the results of curing the patients with postoperative hernias of abdominal wall]

Authors have analyzed the results of curing of 90 patients with postoperative hernias of abdominal wall. All patients were operated by applying polypropylene mesh for hernioplasty and draining postoperative wound by Redon method. All patients were separated in two groups. In 1st group (30 patients) wound-draining was with the help of draining system UnoVac. In 2nd group (60 patients) wound-draining was by applying the ordinary vacuum draining system. In 1st group postoperative wound complications were in 2 cases (6,7%), in 2nd in 16 (26,7%).

Internal herniation through the mesenteric opening after laparoscopy-assisted right colectomy: report of a case

We discuss a rare complication in a patient who underwent laparoscopic colectomy. A 69-year-old woman underwent laparoscopy-assisted right colectomy for cancer of the ascending colon. Two months after the operation, bowel obstruction developed. Decompression with a long intestinal tube failed to resolve the obstruction. Thus, surgery was performed. Abdominal exploration revealed a strangulated ileal loop caused by herniation through the mesenteric opening at the anastomotic site. The mesenterium had not been sutured during the previous operation. The anastomotic segment had twisted semicircularly and adhered to the retroperitoneum, so the mesenteric opening had narrowed.

The biology of hernias and the abdominal wall

The fundamental mechanism for hernia formation is loss of the mechanical integrity of abdominal wall structural tissue that results in the inability to offset and contain intra-abdominal forces during valsalva and loading of the torso. There is evidence that genetic or systemic extracellular matrix disorders may predispose patients to hernia formation. There is also evidence that acute laparotomy wound failure leads to hernia formation and increases the risk of recurrent hernia disease. It may be that hernia formation is a heterogeneous disease, not unlike cancer, where one population of patients express an extracellular matrix defect leading to primary hernia disease, while other subsets of patients acquire a defective, chronic wound phenotype following failed laparotomy and hernia repairs. It is evident that an improved understanding of structural tissue matrix biology will lead to improved results following abdominal wall reconstructions.

Traumatic abdominal wall herniation

Most reported cases of traumatic abdominal wall herniation result from seatbelt or handlebar injuries. The diagnosis is often made on physical examination or abdominal computed tomography (CT). We report a 59-year-old man with traumatic herniation through the rectus muscle following low-velocity blunt abdominal trauma. This patient was initially thought to have a rectus sheath haematoma and initial CT showed a soft tissue haematoma over the left lower anterior abdominal wall but no herniation. The traumatic herniation was diagnosed four days later, and confirmed on CT. Intraoperatively, a segment of the sigmoid colon was found to have herniated through the rectus defect and was gangrenous with impending perforation. A left hemicolectomy followed by primary repair of the defect was done. This case highlights the need for a high index of suspicion for traumatic herniation in patients who sustain low-velocity blunt abdominal wall trauma even when initial CT scans are negative.

[Interdisciplinary approach to treatment of multiple arterial aneurysms in patient with eighth recurrence of incisional hernia--a case report]

Vascular surgery is not the only option for arterial aneurysm treatment. Minimally invasive techniques are being increasingly used, especially methods of interventional radiology. We present a case of a 51-year-old man who came to our department in July 2005 because of sonographically diagnosed popliteal artery aneurysm. Simultaneous presence of subrenal abdominal aortic aneurysm, bilateral iliac and femoral artery aneurysms and left popliteal artery aneurysm was found. This patient was operated on for pancreatic pseudocyst in 2000 and then during next three years eight times for incisional hernia and its recurrences. The operations were carried out in other surgical departments. Eighth recurrence of incisional hernia was already present. Because of these facts, the risk of resection was deemed too high. Therefore, we chose stent graft implantation for abdominal aortic aneurysm treatment. The endovascular approach was also used to treat some complications that occurred. In this case report, we would like to present a combination of surgical and interventional radiological approaches to treatment of arterial aneurysms as a typical example of interdisciplinary cooperation.

A complication of Roux-en-Y gastric bypass: intestinal obstruction

BACKGROUND

Intestinal obstruction is a significant and increasingly recognized complication after laparoscopic and open gastric bypass.

MATERIALS AND METHODS

The medical records of 3,463 patients who had gastric bypass during the study period from July 1997 to December 2004 at a single bariatric center were evaluated. 1,120 patients had retrocolic, retrogastric Roux limb placement and 2,343 patients had antecolic, antegastric.

RESULTS

40 patients had 44 intestinal obstructions (1.27%). The onset ranged from 1 day to 7 years postoperatively (mean 16.9 months). Internal hernia at the transverse mesocolon defect was the most common cause. 36 (3.2%) obstructions were observed in retrocolic, retrogastric vs. 8 (0.3%) in antecolic, antegastric approach. Internal hernia repair at mesocolinic effect (n = 11), jejunojejunostomy mesenteric defect repair (n = 7), lysis of adhesions (n = 16) were the most common procedures. A total of 70.5% were done laparoscopically.

CONCLUSIONS

A high index of suspicion is needed to diagnose bowel obstruction after gastric bypass. Radiological imaging of the abdomen has significant limitations. Surgical exploration should be performed without delay. Diagnostic laparoscopy is a safe and effective therapy. We recommend closing all mesenteric defects to prevent internal hernias. The antecolic, antegastric technique reduces the incidence of internal hernias.

Laparoscopic management of drain-site incisional hernias following laparotomies--a simple suture technique

BACKGROUND

Herniation through drain sites is a rare but recognized complication of surgical drainage and are actually considered to be a type of incisional hernia. Incisional hernias form following surgery through the incision site or previous drain sites, or through laparoscopic trocar insertion sites.

PATIENTS AND METHODS

In this paper, we present 13 such patients with incisional hernia of the main laparotomy wound and at the drain site, and 1 patient with an isolated drain-site hernia. A laparoscopic meshplasty with a simple suturing of the drain-site defect was performed.

DISCUSSION

Incisional hernias are reported to occur in approximately 4%-10% of patients following open surgical procedures. There are several studies that have proven the efficacy of laparoscopic repair of incisional hernias, when compared to open procedures. The main predisposing factor regarding incisional hernias is probably the presence of a sepsis during the previous laparotomy, which was why the drainage tube was kept in the first place.

CONCLUSIONS

The laparoscopic approach is useful for repairing the main incisional hernia, as well as drain-site hernias, simultaneously. We cut costs by avoiding tacking devices and use intracorporeal suturing instead.

[Laparoscopic repair of giant incisional hernia after abdominal wall reconstruction]

Laparoscopic repair of giant incisional hernias, traditionally treated using the open technique with abdominal wall reconstruction, represents a development in the operative method with fewer peri- and post-operative complications. The authors present a patient with a giant incisional hernia after primary right hemipelvic chondrosarcoma and pelvic resection. The patient was treated with laparoscopic repair, in which a large prolene mesh was implanted, and the patient had an uncomplicated post-operative course.

Management of adult incisional hernias at the University of Maiduguri Teaching Hospital

BACKGROUND

Incisional hernias (IH) represent a breakdown or loss of continuity of a fascial closure. They are thus unique as the only external wall hernias that are iatrogenic in aetiology. Incisional hernias are not uncommon complications of laparotomy closure with reported incidence of 2 to 11%.

OBJECTIVES

To review our experience,with incisional hernaia identify possible risk factors and proffer preventable strategies.

PATIENTS AND METHODS

All case records of adult patients managed with IH at the University of Maiduguri Teaching Hospital between January 1995 and December 2004 were retrieved from the Medical Records Department. Relevant data on age, sex, type and institution of index surgery (General Hospital or Private Hospital), premorbid factors, type of repair, post-operative complications were extracted. Case records with inadequate information were excluded.

RESULTS

Between January 1995 and December 2004 a total of 440 patients with external abdominal hernias were treated at UMTH. Out of these: 38 (11.6%) were Incisional hernias and form the basis of this study. Their ages ranged between 18 and 80 years, with peak age range of 40-49 years. There were 6 males and 32 females giving a male to female ratio of 1:5.3. The commonest index surgeries were caesarean section in 12 patients (31.6%) and appendicectomy 10 patients (26.3%). Of the index surgeries 26 (68.4) and 10 (26.3) were performed in general and private hospitals respectively. Only 2(5.3%) were done at UMTH. Wound sepsis, in 18 patients (47.4%), postoperative cough, 8 (21.1%) and obesity 6 (15.8%) were the commonest risk factors. Poor surgical technique was found in 36 patients (94.7%) Most of the patients presented late; 8(21.1%) with recurrence and 6(15.8%) were giant in size. All but one were successfully repaired. Only one (2.3%) had recurrence. There was no mortality.

CONCLUSIONS

Incisional hernias are not uncommon constituting 11.6% of all adult external abdominal wall hernias repaired at UMTH. Most of the causes are preventable with 94.7% of the index surgery done at peripheral hospitals where poor surgical technique was common to all. There is urgent need to re-train our general duty doctors on proper surgical techniques of abdominal wound closure.

Medical effectiveness and safety of conventional compared to laparoscopic incisional hernia repair: a systematic review

BACKGROUND

Incisional hernias are a common complication following abdominal surgery and represent about 80% of all ventral hernia. In uncomplicated postoperative follow-up they develop in about 11% of cases and in up to 23% of cases with wound infections or other forms of wound complications. While conventional mesh repair has been the standard of care in the past, the use of laparoscopic surgery is increasing. It therefore remains uncertain which technique should be recommended as the standard of care.

OBJECTIVES

To compare the medical effectiveness and safety of conventional mesh and laparoscopic incisional hernia repair.

METHODS

A structured literature search of databases accessed through the German Institute of Medical Documentation and Information (DIMDI) was conducted. English and German literature published until August 2005 was included and their methodological quality assessed.

RESULTS

The search identified 17 relevant publications and included 15 studies for final assessment. Among those were one meta-analysis, one randomized clinical trial (RCT) ,and 13 cohort studies. All studies suffered from significant methodological limitations, such as differences in baseline characteristics between treatment groups, small case numbers, and the lack of adjustment for relevant confounders. Overall, medical effectiveness and safety were similar for both surgical approaches. However, there was a trend towards lower recurrence rates, length of hospital stay, and postoperative pain as well as decreased complication rates for the laparoscopic repair in the majority of studies. The impact of the technique of mesh implantation and mesh fixation as well as the impact of certain patient-related factors was not systematically assessed in any of the studies.

CONCLUSION

No conclusive differences could be identified between the operative techniques. There was, however, some evidence for a trend towards similar or slightly improved outcomes associated with the laparoscopic procedure. There remains an urgent need for high-quality prospective studies to evaluate this question conclusively.

[Internal abdominal hernias]

Internal hernias are complete or partial protrusions of one or several viscera or tissues through an intraperitoneal orifice remaining in the abdominal cavity. Whatever the type or anatomical location may be, the seeming banality and lack of specific symptoms contrasts with the seriousness of complications such as strangulation followed by ischemia or intestinal necrosis. Delay in diagnosis can be shortened if these complications are kept in mind at diagnosis and if the imaging studies are illustrative. At the least doubt, surgery will correct the diagnosis and allow adapted treatment.

Laparoscopic mesh repair of transverse rectus abdominus muscle and deep inferior epigastric flap harvest site hernias

INTRODUCTION

The transverse rectus abdominus muscle (TRAM) flap is one of the treatment options for breast reconstruction. TRAM flap reconstruction donor site herniation rates range from 1% to 8.8%. Traditionally, these hernias were treated by an open primary repair with or without the addition of onlay mesh. We report laparoscopic approach to treat TRAM and deep inferior epigastric perforator flap (DIEP) harvest site hernias with mesh.

CASES

We treated 5 patients, 4 from TRAM and 1 from DIEP flap harvest site hernias during the period of October 2003 to January 2006. Two of these patients underwent previous open mesh repair with recurrence. All of these patients underwent laparoscopic hernia repair using polytetrafluoroethylene dual mesh. Follow-up ranged 6 to 31 months without any recurrences.

CONCLUSIONS

Laparoscopic mesh repair of ventral hernias located at TRAM and DIEP flap harvest sites can be performed safely and with a low rate of recurrence.

Perineal hernia after laparoscopic abdominoperineal resection for rectal cancer: report of two cases

Perineal hernias are uncommon complications after open abdominoperineal resection. We present two patients with a perineal hernia after laparoscopic abdominoperineal resection. Surgical correction of symptomatic hernias is a challenging problem caused by the effects of preceding surgery. The surgical management with a mesh is described and discussed in this case report.

Cannula Site Insertion Technique Prevents Incisional Hernia in Laparoscopic Fundoplication

INTRODUCTION

Incisional hernia is a common surgical problem encountered after laparotomies. The so-called trocar-site or port-site hernia is a type of incisional one that occurs after laparoscopic procedures. It has an incidence range between 0.1% and 3%.

OBJECTIVE

To evaluate our patients who underwent laparoscopic Nissen fundoplication for presence of trocar-site hernia.

PATIENTS AND METHODS

This study included 405 patients who underwent laparoscopic Nissen fundoplication in Ankara University, Faculty of Medicine, Department of General Surgery, Turkey. The patients were evaluated by physical examination and anterior abdominal wall ultrasound (US).

RESULTS

Trocar-site hernia was not detected in any of our cases either by physical examination or by US.

CONCLUSIONS

Trocar-site hernia is a rare complication of laparoscopy. It occurs at the trocar insertion site with a diameter of 10 mm or more in adult patients. Trocar insertion away from the midline can decline the incidence.

Abdominal wall repair using human acellular dermis

BACKGROUND

The surgical repair of abdominal wall defects that cannot be closed primarily in contaminated fields is a difficult problem. The use of nonabsorbable synthetic materials usually is contraindicated in this setting because of the risk for colonization and chronic infection of the mesh. In this study we sought to determine the safety and efficacy of implanted human acellular dermal graft for abdominal wall reconstruction.

METHODS

The records of all patients (n = 20) who underwent a repair of an abdominal wall defect with human acellular dermal graft at a Veteran Affairs hospital were reviewed retrospectively. Patient demographics, complications, and hernia recurrence were recorded.

RESULTS

There were 15 perioperative complications in 11 patients: 6 graft dehiscences, 1 evisceration, 2 postoperative intra-abdominal bleeds, 5 bacterial graft infections, and 1 death. Patients with heart disease, American Society of Anesthesiologists classification of 4, and/or dirty wounds were more likely to have perioperative complications. The median follow-up period was 9.4 months (range, 2-16 mo), during which 6 hernia recurrences were noted.

CONCLUSIONS

Human acellular dermis use is safe in abdominal wall reconstructions in contaminated surgical wounds.

Incisional hernia following liver transplantation: incidence and predisposing factors

BACKGROUND

Patients after orthotopic liver transplantation (OLT) have a high risk of developing incisional hernia (IH). In the literature incidences between 5% and 17% are reported.

PATIENTS AND METHODS

In 90 patients, who underwent OLT between October 1998 and December 2005, a retrospective analysis on the occurrence of IH was performed. Surgical access for OLT was a transversal upper laparotomy. Age, gender, primary disease, ICU stay, immunosuppressive regimen and two different closure techniques (running suture or single sutures in layers) were evaluated.

RESULTS

In 73 patients (76.7%, group 2) healing of the incision was without problems, in 17 patients (23.3%, group 1), IH occurred. Total survival was similar between the groups (86.3% vs. 94.1%, n.s.). No significant differences between the groups concerning age, gender, body mass index, platelet count and duration of ICU stay were found. Also, the technique of abdominal closure had no impact on the development of IH. No IH was found in patients with hepatocellular carcinoma (n = 15), whereas end-stage liver cirrhosis (n = 75) was associated with development of IH (p = 0.064). Multivariate analysis revealed end-stage liver cirrhosis, Sirolimus, and MMF to be independent significant risk factors for IH after OLT.

CONCLUSION

IH following OLT has to be regarded a frequent complication. While technique of abdominal closure seems to have no impact, primary diagnosis and kind of immunosuppressive regimen exerted a significant influence on the formation of IH.

Traumatic abdominal wall hernia (TAWH): a case study highlighting surgical management

We report a rare case of traumatic abdominal wall hernia (TAWH) caused by a traffic accident. A 47-year-old woman presented to the emergency room soon after a traffic accident. She complained of diffuse, dull abdominal pain and mild nausea. She had no history of prior abdominal surgery or hernia. We found a bulging mass on her right abdomen. Plain abdominal films demonstrated a protrusion of hollow viscus beyond the right paracolic fat plane. Computed tomography (CT) showed intestinal herniation through an abdominal wall defect into the subcutaneous space. She underwent an exploratory surgery, followed by a layer-by-layer interrupted closure of the wall defect using absorbable monofilament sutures without mesh and with no tension, despite the large size of the defect. Her postoperative course was uneventful.

Incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall protruding through the stoma

The case is reported of incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall protruding through the stoma. An 82-year-old woman presented with suspected parastomal intestinal hernia. The patient had undergone total cystectomy with ileal conduit construction 3 years previously, followed by stomal reconstruction surgery for stomal stenosis 2 years later. She had been taking various kinds of purgatives for severe constipation. Initially, this case was diagnosed as parastomal hernia, but emergency surgery demonstrated that incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall was protruding through the stoma. This case was apparently caused by high abdominal pressure and thinning of the ileal conduit wall.

Laparoscopic repair of a paracolostomy hernia: secure reinforced closure of the defect prevents recurrence

High incidence rates have been reported for parastomal hernias after colostomies, particularly end colostomies. In addition to cosmetic disfigurement, parastomal hernias also cause several functional problems in stoma management, and their repair becomes essential. While a variety of open techniques have been described for their management, including the extreme step of stoma relocation, laparoscopic techniques offer a viable and possibly better option. We present a case of parastomal hernia and describe our technique of repair.

Role of biomarkers in incisional hernias

Incisional hernias represent one of the most common complications of laparotomies. Previous investigations have suggested that a disorder in collagen fiber structure and production level may be an important pathologic cause of abdominal wall hernias. We hypothesized that a cross-examination of multiple extracellular matrix biomarkers might identify underlying defects contributing to the development of hernias. We examined two patient populations: patients with incisional hernias (presenting for hernia repair) and patients with no hernia after previous laparotomy (undergoing a second laparotomy). Patients with previous wound infections, open abdomens, or on steroids were excluded. Fascia samples were obtained from all patients at the time of their second operation and they were studied. Western blots and reverse transcriptase-polymerase chain reaction were used to determine the ratio of type I, III, and IV collagens, as well as matrix metalloproteinase 1 (MMP1) and MMP2 in both groups. Values of P < 0.05 were considered statistically significant. At the protein level, collagen I/III ratio was slightly decreased in patients with incisional hernias compared with those with no hernia, whereas it was significantly decreased at the mRNA transcript level (0.49 vs 1.03, P < 0.01, respectively). The MMP-1 mRNA transcripts were not different in incisional hernia (IH) versus nonincisional hernia, but the MMP-2 level was significantly increased in patients with IH. Reduced collagen I/III and MMP-1/MMP-2 ratios in IH might be consequence of the biological activities between key elements participating in the development of IH after laparotomies. The potential role of MMP-2-specific inhibitors in preventing IH is of significance for future studies.

Definitive reconstruction of full-thickness abdominal wall defects initially treated with skin grafting of exposed intestines

BACKGROUND

The reconstruction of wide, full-thickness abdominal wall defects of the midline presents a continuing challenge, and consensus concerning the appropriate surgical treatment is lacking.

METHOD

In this retrospective review, we describe a simple method of reconstruction in full-thickness defects initially treated with skin grafting directly on to the surface of the intestines. Instead of removing the split-thickness grafts from the surface of the intestines, the abdominal wall was reconstructed by inverting the grafted area and advancing the rectus muscles towards the midline.

RESULTS

Four patients with full-thickness transverse defects larger than 10 cm at the level of the waist and extending from the xiphoid to the suprapubic region were operated with this method. All healed uneventfully. In one case, microscopic examination of the inverted skin showed transformation to normal connective tissue.

CONCLUSION

Reconstruction of abdominal wall defects previously treated with skin grafting directly on to the intestines can be safely done by reposition of the skin-grafted intestines into the abdominal cavity and realignment of the rectus muscles in the midline.