Abdominal wall hernias

Clinical pictures mimicking acute hernia complications: are we really daring to violate a traditional abdominal wall surgery dogma?

Background

Acute abdominal wall hernia complications usually require a prompt surgical treatment. The aim of this case series is to report our experience with some unusual cases of apparent acute and subacute hernia complications not requiring surgical treatment, changing the classical paradigm of immediate surgical approach into a “wait and see” situation.

Case presentation

We shortly report here four cases of abdominal wall hernia complications in which surgical treatment could have been unsafe for the patients considering their clinical condition. Two cases were fistulated and two were apparently strangulated. After clinical evaluation and CT-scan, we opted for a conservative treatment weighting the risk–benefit balance in order to give the best quality of life to the patient.

Conclusions

In selected cases and under well-defined situations, an accurate evaluation should convince every surgeon to opt for a conservative approach refraining from a promptly operative treatment of the patient. This may be particularly relevant among very old or high-risk patients affected by long-standing abdominal wall hernias.

Incarcerated umbilical hernia leading to small bowel ischemia

A 59-year-old male with history of hepatitis C, refractory ascites requiring multiple paracentesis and transjugular intrahepatic portosystemic shunt placement presented to the emergency department with 2 days of abdominal pain. Physical examination revealed blood pressure of 104/66 and pulse of 94. The abdomen was remarkable for distention and a tender incarcerated umbilical hernia. The skin overlying the hernia was pale with areas of necrosis. The patient immediately underwent laparotomy which was successful.

Risk of death after emergency repair of abdominal wall hernias. Still waiting for improvement

PURPOSE

The precise importance of factors affecting morbidity and mortality in patients with complicated abdominal wall hernias undergoing emergency surgical repair has been not completely elucidated.

PATIENTS AND METHODS

A retrospective multicentric study of all patients (n = 402) with abdominal wall hernia who underwent urgent operations over 1-year period was conducted in ten hospitals. Logistic regression analysis was used to evaluate variables that affect morbidity and mortality.

RESULTS

Thirty-five percent of patients had inguinal hernia, 22% femoral hernia, 20% umbilical hernia, and 15% incisional hernia. Mesh repair was used in 92.5% of cases. Intestinal resection was required in 49 patients. Perioperative complications occurred in 130 patients, and 18 patients died (mortality rate 4.5%). Complications and mortality rate were significantly higher in the group of intestinal resection. Patients older than 70 years also showed more complications, required intestinal resection more frequently, and had a higher mortality rate than younger patients. In the logistic regression analysis, age over 70 years, intestinal resection, and American Society of Anesthesiologists (ASA) III/IV class emerged as independent predictors of a poor outcome. Based in our results, we propose a simple schema to calculate risk of death in these patients.

CONCLUSION

Using multivariate logistic regression analysis, probabilities of death after complicated abdominal wall hernia surgery are increased in patients with: age over 70 years, high ASA class, and associated intestinal resection. Guidelines should be developed to improve prognosis in these patients.

Emergency presentation of abdominal hernias: outcome and reasons for delay in treatment - a prospective study

INTRODUCTION

Emergency hernia surgery is associated with a higher postoperative complication and a less favourable outcome. The aim of this study was to audit emergency presentations of abdominal hernias prospectively in order to identify delays in patient treatment.

PATIENTS AND METHODS

Prospective audit was carried out between January and September 2003 of all patients presenting acutely with symptomatic hernias. In total, 55 patients presented, 39 of whom needed surgical intervention. The emergency repairs were compared with a cohort of elective repairs performed in the trust at the same time.

RESULTS

The median age was 77 years (range, 5-92 years; 35 male, 20 female). The distribution of the hernias, requiring surgery, was inguinal (19), para-umbilical (10), incisional (5) and femoral (5). The overall complication rate was 46.2% and the in-patient stay was 4 days (range, 1-49 days). Six patients required small bowel resection. Conservative management was identified as a key contributing factor in the delay of treatment. There was a significant increase in the in-patient stay, the early complication rate and the small bowel resection rate in the emergency repairs.

DISCUSSION

Patients with a symptomatic hernia should be offered elective, surgical repair. Non-operative management is inappropriate for the vast majority of cases, especially when many repairs may be performed with local anaesthetic infiltration. Clinicians should be aware of the high morbidity associated with the emergency repair of abdominal hernias in the elderly.

Extraperitoneal Laparoscopic Approach to Spigelian Hernia Combined With Groin Hernias

Spigelian hernia is a rare form of abdominal wall hernia. It occurs when peritoneum with or without organs or preperitoneal fat exists through a defect in the Spigelian fascia. A 63 year old male patient complaint of inguinal hernias and Spigelian hernia treated with laparoscopic approach that has been not previously reported in the literature. The use of the laparoscope has simplified the diagnosis, clarified its localization, and facilitated the subsequent repair of these hernias.

Color Doppler sonography for ventral hernias in patients with acute abdomen: preliminary findings

PURPOSE

We assessed the usefulness of color Doppler sonography (CDUS) in evaluating the vascular status of ventral hernias and distinguishing incarcerated from nonincarcerated ventral hernias.

METHODS

In this prospective study, 10 patients who presented with acute abdomen and had ventral hernias underwent CDUS from August 1999 to May 2000. Patient age and sex and the clinical severity, mode of therapy, and outcome in these 10 patients were evaluated in relationship to the CDUS findings.

RESULTS

Five patients had readily visible flow in the bowel within the hernial sac on CDUS. Two of these 5 had spontaneous reduction under conservative treatment, and 3 had asymptomatic ventral hernias with acute abdomen caused by spontaneous bacterial peritonitis. Barely visible flow was visualized in the bowel by CDUS in 4 other patients. Three of these underwent emergency surgery because of peritoneal signs; 2 of them were found to have ischemic changes in the bowel. The fourth patient underwent a successful manual reduction. The remaining patient had absent flow in the bowel on CDUS and underwent emergency surgery, which revealed gangrenous changes in the bowel.

CONCLUSIONS

The intensity of the Doppler signals on CDUS appears to be a promising predictor of bowel viability in cases of ventral hernia. Thus, CDUS should impact the determination of the treatment plan, including whether to provide conservative treatment or surgery.