Sabiston Textbook of Surgery, 18th Ed

Hernias

December 9th, 2010 University of Colorado Health Science Center Department of surgery

Erik Peltz, D.O.

Background

Hernia: abnormal protrusion of an organ or tissue through a defect in its surrounding walls.
Reducible: Contents can be replaced Incarcerated: Cannot Strangulated: Compromised blood supply External vs Internal vs Interparietal Richters hernia

Hernia:

Background

5% of patients will develop an abd wall hernia 75% 15 20% 10% 5% inguinal region incisional umbilical and epigastric femoral

Background

Groin hernias M:F 25:1 Femoral F:M 10:1 Umbilical F:M 2:1

Indirect:Direct 2:1

Inguinal vs Femoral hernia ? Inguinal are more common than femoral hernias in both M, F

10% of females and 50% of males with femoral hernia will develop and inguinal hernia

Background

Indirect Inguinal hernia Which side is more common?

More common on right Slower descent of right teste Delayed atrophy of the right processus vaginalis

Femoral Hernia
More common of right Tamponade of sigmoid colon protecting Left? 15 20% rate of incarceration.

Mandate operative repair when diagnoses

Anatomy

Anatomy

Inguinal Canal

Contains the spermatic cord / round ligament of the uterus Spermatic cord

Cremasteric muscle inferior extension of internal oblique Testicular artery (aorta), Veins (left renal, right IVC) Genital branch genitofemoral nerve Vas deferens Lymphatics Processus vaginalis

Hesselbachs triangle

Bounderies Inferior Epigastrics

Superior Lateral border Medial border Inferior border

Rectus Sheath

Inguinal Ligament

direct Hernia

indirect Hernia

Associated Nerves

Iliohypogastric (L1) suprapubic / inguinal sensation

Beneath the interal obl. at the ASIS Penetrate I.O. and course superior / medial

Ilioinguinal (L1) Inguinal / scrotal / proximal thigh

Beneath the interal obl. At the ASIS Penetrates I.O. and courses superior / medial overlying cord

Genital branch (L1 L2), genitofemoral

Courses with the cremaster fibers in the spermatic cord Cremaster motor Scrotal sensation

Femoral Canal

Boundaries

Iliopubic tract anteriorly Coopers ligament posteriorly Femoral vein laterally

Differential Diagnosis

Inguinal hernia Femoral hernia Adenitis Varicocele Ectopic teste Lipoma Hematoma Sebaceous cyst Hidradenitis Lymphoma

Metastatic neoplasm Epididymitis Testicular torsion Vascular aneurysm / Pseudoaneurysm

Diagnosis

Hx / PE

Supine and Standing Valsalva Invagination of scrotum to inspect canal Inguinal adenopathy? Hx CA? Rectal Exam? Colonoscopy? Bulge below inguinal ligament Femoral Hernia Comorbidities: Pulmonary, Cirrhotics, renal failure / dialysis, Constipation / GI / Colon CA?

Diagnosis

Imaging:

Ultrasound: sensitive and specific CT Laparoscopy

Non-operative management

Fitzgibbons et al., JAMA 2006

700 pts randomizes to non-op vs operative repair 25% non-op pts crossed over (pain / enlargement) Incarceration with non-op 0.03% No difference in operative outcome with watchful waiting (SSI, OR time, Recurrence Rates)

Operative management

Tissue Repair

High recurrence rates largely replaced by mesh repairs Remain useful / important in certain situation Strangulated hernias / bowel resection / infection Iliopubic Tract Repair Shouldice Bassini McVay

Tissue Repair

Iliopubic Tract Repair

Approximates the transversus abdominis / conjoint tendon to the iliopubic tract.

Tissue Repair

Bassini Repair

Single layer repair T. Abdominis / IO / conjoint tendon to the inguinal ligament

Tissue Repair

Shouldice Repair

Multi-layer repair T. Abdominis incised Overlap T.A. Free edge of T.A. Iliopubic tract. 2nd deep layer of interal oblique / T.Abdominis to inguinal ligament May incorporate relaxing incision Low recurrence rate for tissue repair (2%)

McVay Tissue Repair

McVay Repair

Multi-layer Very useful in incarcerated or strangulated femoral hernias. Approximates Transversus Abdominis to Coopers Ligament (postero-medial aspect of femoral canal) Relaxing incision in posterior aspect of the anterior rectus sheath then allows layered closure of internal oblique to inguinal ligament tension free fashion.

McVay Tissue Repair

Lichtenstein

Mesh Repair

Tension is the pricinpal cause of recurrence

Tension Free Mesh Repair

Lichtenstein

Tension is the pricinpal cause of recurrence mesh placed to reinforce the inguinal floor / Internal ring

May be sutured to conjoint / internal oblique and iliopubic tract

Results: Several Randomized Controlled Trials Recurrence 0% - 3.5% Critics note short follow-up (1-3 yrs) in many of these trials. Rate is better than 5 15% reported for many primary tissue repairs.

Pre-peritoneal Repair

Preperitoneal Repair

Involves initial incision 2cm cephalad to the internal ring. Dissection to the preperitoneal plane through the anterior rectus muscles Both primary and mesh repairs described. Very useful open approach for:
Recurrent Hernias Sliding Hernias Stangulated Hernias Femoral Hernias

Laparoscopic Inguinal Repair

Trans-abdominal Preperitoneal (TAPP) Totally Extraperitoneal Very useful for bilateral hernias / recurrence

Recurrence Rates from RCT 0 10% Veterans Admin RCT

TEP vs Lichtenstein Recurrence 10% vs 5% Surgeon experience with technique questioned

Special Considerations

Sliding Hernia

Internal organ comprises a portion of the wall of the hernia sac. (Colon or Bladder) Careful identification before injury to organ McVay, open preperitoneal, laparoscopic Open preperitoneal Allows single incision evaluation, resection and repair of hernia

Recurrent

Stangulated

Complications

SSI

1 2% open, less with laparoscopic No abx necessary for elective repair

Including placement of mesh ASA > 3, comorbidities, strangulation, etc

Abx for:

Complications

Nerve Injury

Traction, electocautery, transection, entrapment Ilioinguinal, Iliohypogastric, Genitofemoral Lateral femoral cutaneous (laparoscopic) Chronic pain has surpassed recurrence as the leading postop complication (29 76%)

Complications

Ischemic Orchitis

Thrombosis of pampiniform plexus veins Tender / swollen teste POD 2 5 Continues for 6 12 wks Test atrophys

Complications

Recurrence:

1 3% tension free and laparoscopic repairs

Most commonly recur within 2 yrs

Shouldice has the lowest reported recurrence rate for tissue repairs 2%

Umbilical Hernia

Congenital in infants

Most close by 2yoa. Repair if persist after 5yoa. Obesity, ascites, pregnancy, abdominal distension Primary Repair vest over pants 10 30% recurrence rate < 3 cm may primarily repair with interupted suture > 3 cm mesh under lay, overlay, +/- primary closure

Adults acquired

Epigastric Hernia

2 3 times more common in men Often incarceration of preperitoneal fat

Pain

20% multiple 80% off of the midline Repair similar to umbilical hernia

Surgical Site Infections

Causes and Risk Factors

Bacterias Fault BACTERIA Surgeons Fault Remote site infection Patients Fault Long-term care facility
Recent hospitalization Duration of procedure Wound class ICU Patient Previous Abx Preoperative shaving

(Microorganism) LOCAL WOUND (Local Wound Factors) Surgical Technique (Patient Factors) Hematoma / seroma
Necrosis Sutures Drains Foreign bodies

PATIENT
Age Immunosuppression Steroids Malignancy Obesity Diabetes / Glucose Control Malnutrition Comorbidities Transfusions Cigarette Oxygen Delivery Temperature

Bacterial #, virulence, resistance

Surgical Site Infections

Preventative Measures for SSI

Bacteria
-Shorten Preop Stay -Antiseptic Shower -Hair Clippers -Postpone Surgery or treat remote infection -Apporpriate Prophylaxis -Bowel Prep? -Asepsis -Antisepsis -Control Spillage -DSG 48 72 hrs -Early Drain Removal -Avoid Postop Bacteremia

Timing of action
Preoperative

Local
-Hair Clippers

Patient
-Optimize Nutrition -Pre-operative Warming -Strict Glucose Control (80 110) -Smoking Cessation

Intraoperative

-Supplemental O2 (80%) -Intra-operative Warming -Fluid Resuscitation -Strict Glucose Control -Early Enteral Nutrition (EAST) -Supplemental O2 -Strict Glucose Control -Surveillence Programs

Postoperative

Bacterias Fault

Asepsis and Antisepsis Practices

Chlorhexidine Shower

No reduction in SSI. Do reduce bacterial colony count.

CDC recommendation Cardiac, Vascular, Prosthetic Procedures

No shave Germicidal Skin prep Surgical scrub Sterile technique

Gowns/masks/hats/gloves/OR FOOT TRAFFIC

Antimicrobial Prophylaxis

Enteral (Abx bowel prep)

Non-absorbable antibiotics to suppress both aerobic and anaerobic intestinal bacteria.

Neomycin + Erythromycin at 19, 18 and 9 hours before surgery. (Nichols Prep)

Effect of Preoperative Neomycin-Erythromycin Intestinal Preparation on the Incidence of Infectious Complications Following Colon Surgery. Nichols, RL et al. Ann Surg. 1973; 178(4): 453-462.

Meta-analyses have recently shown no benefit over IV Abx and when combined with mechanical prep there is a trend towards increased anastomotic leaks.

Antimicrobial Prophylaxis

Intravenous

Clean Cases

Not indicated for low-risk, straightforward clean procedures with no obvious bacterial contamination or insertion of a foreign body.

All others: Abx appropriate to anticipated flora should be given within one hour of incision and redosed at 1 2 half lives for longer cases.

Antimicrobial Prophylaxis

Intravenous

No anticipated entry into colon / distal small bowel

Ancef Clindamycin (cephalosporin allergy)

Potential SB / Colon
Must cover for obligate anaerobic bacteria (Bacteroides) Cefotetan, Cefoxitin (shorter T )

Antimicrobial Prophylaxis

Intravenous

Concern for MRSA (IVDA, Institutionalized, NH, recent hospitalization)

Vanc

Patients Allergic to Cephalosporins with planned bowel surgery

Aminoglycoside or Flouroquinolone + Clinda or Flagyl Aztreonam + Clinda or Flagyl Zosyn, Ertapenem, etc

Antimicrobial Prophylaxis

Common flora

Biliary Tract: Chronic Cholecystitis: < 1% SSI

Gram Positive
Enterococcus Streptococcus

Gram Negative
Klebsiella Escherichia coli Enterobacter Pseudomonas Citrobacter Proteus

Anaerobes
Bacteroides Clostridium

Fungi
Candida

Open Chole
Ancef

Lap Chole
Low risk NONE High risk Ancef

Open Biliary
Unasyn, Carbepenems, Cipro +Flagyl, Cefotetan, Cefotaxime, Ceftriaxone

ERCP
Low risk None High risk Unasyn, Carbepenems, Cipro +Flagyl, Cefepime

Antimicrobial Prophylaxis

Common flora

Appendicitis:
Aerobic / Facultative Anaerobes
Escherichia coli Viridans strep Pseudomonas Group D strep Enterococcus

Anaerobic

Must cover aerobic and anaerobic bacteria

Cefoxitin, Cefotetan Levo + Flagyl Zosyn ?, Ertapenem ?

Bacteroides fragilis Bacteroides spp Peptostreptococcus Bilophila Lactobacillus Fusobacterium

Antimicrobial Prophylaxis

Common flora

Colon:
Bacteria make up to 90% of the dry weight of feces. 109 Organisms/ml feces

Aerobic
Escherichia coli Enterococcus Proteus Streptococcus Pseudomonas

Anaerobic
Bacteroides fragilis Peptostreptococcus Bilophila Lactobacillus Fusobacterium

Must cover aerobic and anaerobic bacteria

Cefoxitin, Cefotetan Levo + Flagyl Zosyn ?, Ertapenem ?

Complications happen because you want them to happen

Surgical Technique
Careful Tissue Handling Ensure Adequate Blood Supply Adequate Hemostasis Debriedment of Necrotic Tissue Removal of Foreign Bodies Monofilament Sutures Absorbable Sutures Closed Suction Drains to prevent seroma / hematoma Avoid Open Drains (penrose)

Surgeons Fault Surgical Technique

Surgical Technique

Wound Closure

Delayed Primary Closure:

Heavily contaminated wounds or wounds with Targeting closure of devitalized tissue.

wound at point of optimal macrophage Allows for the body to developnumbers adequate inflammatory / / activity

cellular response to potential pathogens

Phagocytic cells progressively increase in number at the wound edges to a peak at approximately day 5. Capillary budding Closure can be accomplished even with high bacterial counts.

Patients Fault

Malnutrition

Pre-op TPN / Enteral Feeds Early post-op Enteral Feeds

Tobacco Pre / Intra / Post-op Warming Glucose Control Adequate resuscitation / CO / O2 deliver?

Specific Surgical Infections

Specific Surgical Infections

Non-Necrotizing Soft Tissue Infections

Cellulitis: Erythema, Warmth, Induration, Pain

Acute inflammatory response Small vessel engorgement / stasis Endothelial leakage / interstitial edema PMN infilitrate

Should

resolve with appropriate Abx coverage

Abscess: All of the above +

Sequelae of necrotic tissue, ischemia, pus Fluctuance

Drainage

/ debriedment for local control

Specific Surgical Infections

Non-Necrotizing Soft Tissue Infections

Abscess:
Head and Neck: S. aureus +/- Strep Axilla: Gram Negative component Below Waist: Mixed aerobic and anaerobic gram neg.

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Absence of clear local boundaries or palpable limit Layer of necrotic tissue not walled off by surrounding inflammation

Mortality

16% - 45%

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Overlying skin may look remarkably NORMAL

Rapidly progressive infection within the superficial subcutaneous fascial planes. Bounded by deep investing fascia. Inflammation / edema / +/- sub-Q air / Tense / Tender to palpation Late signs are erythema / ecchymosis / cyanosis / blisters secondary to perforating vessel thrombosis.

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Imaging:

CT, MRI: Inflammation (enhances on T2 imaging) / edema within superficial tissues / Sub-Q gas ? These modalities are sensitive but non-specific. High index of suspicion to avoid delay in definitive therapy Extensive fascial debriedment.

Specific Surgical Infections

Critical Care Medicine, 2004; 32(7): 1535 1541 Singapore

Retrospective Study n = 89 pts admitted for Nec. Fasc. n = 225 controls Employed regression model to evaluate various laboratory values at admission to predict risk of Necrotizing Fasciitis.

Specific Surgical Infections

Specific Surgical Infections

Critical Care Medicine, 2004; 32(7): 1535 1541 Singapore

LRINEC Predictive Value

Risk Group Low Risk Moderate Risk High Risk LRINEC SCORE LRINEC < 5 LRINEC 6 7 LRINEC 8 PROBABILITY OF NEC. FASC. 50% 50% - 75% >75% 6; PPV 92% NPV 96% 8; PPV 93.4% PREDICTIVE VALUE

Specific Surgical Infections

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Finger Test
2 cm incision made down to deep fascia + Test

Lack of bleeding Thrombosed vessels Dishwater exudate Lack of resistence to finger dissection

Frozen Section

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Necrotizing Soft Tissue Infections require emergent wide excision of all clinically involved tissues.
Re-operation within 24 hours, or sooner Systemic support for impending severe sepsis Extremity involvement often requires amputation to control local infection.

Abx coverage for common organisms

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Variable (on admission)
Heart rate > 110 Temp < 360 C Creatinine > 1.5 mg/dl Age > 50yr WBC > 40 Hct > 50

# points
1 1 1 3 3 3

Group Categories
1 2 3

# Points
02 35 6

Mortality Risk
6% 24% 88%

Anaya DA et al. Predicting mortality in necrotizing soft tissue infections. Surg Infect. 2009; 10(6): 517 522

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

Mortality: 5 50% Definitive therapy is NOT antibiotic management, rather Operative or Interventional drainage. a patient with fever and abdominal pain is not given antibiotics without a plan leading to surgery or other drainage procedure. Administration of antibiotics in this setting before diagnosis may obscure subsequent findings and delay diagnosis and will certainly delay definitive operative management.

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

-Hx consistent with Surgical Process? -Peritonitis? -Acidosis? -Shock -Non-op causes excluded

Does the Patient Need a Hole?

Yes Emergent Operation Source Control

Non-Surgical Causes of Acute Abdomen Endocrine and Metabolic Causes Uremia Diabetic crisis Addisonian crisis Acute intermittent porphyria Hereditary Mediterranean fever Hematologic Causes Sickle cell crisis Acute leukemia Other blood dyscrasias Toxins and Drugs Lead poisoning Other heavy metal poisoning Narcotic withdrawal Black widow spider poisoning Other

Pancreatitis Pyelonephritis Salpingitis Amebic Liver Abcess Enteritis SPB Diverticulitis? Cholangitis?

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

-Hx consistent with Surgical Process? -Peritonitis? -Acidosis? -Shock -Non-op causes excluded

Does the Patient Need a Hole? No

-Additional Labs -Imaging -Serial Exam -Invasive Monitoring -Percutaneous Drainage -Other Intervention (ERCP, PTC, Endoscopy)

Yes

Broad Spectrum Antibiotics

Does the Patient Need a Hole?

Emergent Operation Source Control

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

Abx
Cefoxitin, Cefotetan Timentin Ertapenem Unasyn Imipenem Meropenem Zosyn Flagyl Clinda Vanc

Non-Surgical Infections

UTI #1 nosocomial post-op infection Pneumonia 3rd most common Central Lines Sinusitis