challenges and management strategies of hernia in the obese

HERNIA IN THE OBESE !!!

Challenges n Management Strategies

HERNIACON 2013 @AHEMADABAD

WEL -COME

Dr Sumeet Shah ,Delhi Dr Apoorva Vyas , Ahemadabad Dr Chirag Desai , Ahemadabad Dr Parag Khandelwal ,Ahemadabad

Dr Sunil Popat ,Ahemadabad Dr Jayasshree Todkar , Pune

IS IT REALLY DIFFERENT ???

48 yr old, DM on OHAs, HT, V.V with ulcers, Abd hernia, Chronic smoker, Breathless on slight exertion.

Target: Leg ulcers to heal,Leg edema to be less,Breathlessness less,Drugs less, Play with children

POPULAR BA SX IN INDIA

INCIDENCE ETIOLOGY

Ventral HerniaIncisional Hernia

Over 10,000 cases in India annually Incidence: 2%~11% of all the laparotomies,

15%~20% after abdominal surgery in the obese, 23% of the infected incisions

Risk factors: obesity, aged, anemia, smoking, infection, history of operation, long incision, incision site, emergency operation, increasing IAP, diabetes mellitus, some drugs

Recurrence: 10%~50%

Ventral HerniaUmbilical Hernia

Umbilical hernia in adults Acquired umbilical hernia Increased IAP: obesity, heavy lifting Long history of coughing Multiple pregnancies Three times more common in women Higher risk of strangulation

Etiology :

Various factors are responsible More than one factor may co-exist in a given patient

1) Poor Surgical technique : Inadequate fascial bites Tension of fascial edges Tight closure2) Post-op wound infection3) Age slower in old age4) General debility, Cirrhosis, Carcinoma, Chronic Wasting disease

5) Obesity6) Post-Operative Pulmonary Complications7) Intra Operative blood loss more than 1000ml8) Failure to close fascia of trocar sites over 10mm size

Why Hernia repair is required ?

a) Associated morbidity secondary to incarceration, strangulation

b) Relative loss of abdominal domain with adverse effects on postural maintenance, respiration, micturition , defecation

c) Patients are forced to alter their lifestyle, their ability to work becomes impaired

d) A cosmetic deformity, detrimental to patients self-esteem

Methods of repair :

1. Primary Suture Repair2. Mesh Repair by Open technique3. Component separation4. Flap reconstruction5. Tissue expansion6. Laparoscopic method7. Combination of any methods

Open Mesh Repair :

Use of synthetic mesh in Ventral Hernia Repair has increased since 1987

Advantages :a) Tension free restoration of structural integrity of the abdominal wallb) Easy availability ( thanks to industry )c) Absence of donor site morbidity

Ideal Prosthesis should bed) Non-toxice) Non-immunogenicf) Non-reactiveg) Should get incorporated into the surrounding tissueh) Tensile strength is rarely a problem with available materials

Failures with mesh occurs Laterally at mesh tissue interface

Laparoscopic Repair :

Gaining Popularity Prosthetic material is placed in pre-peritoneal space or

subperitoneal space ( i.e. Intra peritoneal Onlay Mesh Repair )

Large prosthetic support is secured with transfixing sutures or tackers

Sutures are placed at 4-5cm distance Tackers are placed at 1cm distance Alone tackers may lead to recurrence thus few

transfixing sutures required

Advantages :

1. All advantages of minimally access surgery2. Intra abdominal adhesion can be separated3. If enterotomy or serosal injury can be sutured4. Mesh placement to be delayed if enterotomy

but later on, can be completed laparoscopically5. Multiple hernias ( swiss cheese defects ) can be

tackled

Advantages open method over lap

1. Seromas2. Potential risk to intestinal injuries3. Bleeding from abdominal wall vessels4. Pain due to tackers & transfixing Sutures5. Open repair provides opportunity to revise

scarred abdomen & abdominoplasty in selected cases

6. Cost

BARIATRIC SURGERY N HERNIA REPAIR

TECHNIC : OPEN / LAP

Open technique

Laparoscopic Technique :


PORT POSITION, PATIENT POSITION

Ventral HerniaIPOM

Different choice of trocar site base on hernia site

Lateral abdomen

PORT POSITION

Biomaterials

Synthetic Nonabsorbable

Coated Nonabsorbable

Partially absorbable

Biological

Synthetic Nonabsorbable Polypropylene - causes intense inflammation

- causes adhesions

Polyesters - degradable ?

PTFE - no invasion of tissues - encased in fibrosis - more shrinkage - more prone to infection ?

Coated Nonabsorbable(Polypropylene)

C – Qur – polypropylene coated with omega 3 fatty acids does not cause adhesions for 120 days ?

Glucamesh - coated with oat beta glucan

Timesh – titanium coated causes collagen 1 synthesis ?

i. SeprameshMacro porous polypropylene coated on one side with a bio-resorbable. Nonimmuogenic membrane of sodium hyaluronate and Carboxymethyl cellulose on the other side.

ii. ParietexMultifilament polyester mesh with a purified, oxidized bovine atelesllagen type I coating covered by an absorbable, antiadhesion film of polyethylene glycol and glycerol.

iii. ParientenePolypropylene coated with same anti adhesive barrier as above.

Prosthesis With Absorbable Barrier

SEPRAMESH

iv. Proceed Surgical MeshLightweight monofilament polypropylene mesh encapsulated with laminated of polydioxanone coated on one side with the absorbable barrier material oxidized regenerated cellulose.

Multilayered tissue separating Mesh

v. Bard Composix MeshIt is a non absorbable barrier mesh constructed of macro porous polypropylene on one side bonded to low porosity PTFE on the other side.

vi. GORE – TEX Dual MeshIt has two surfaces; one is

very smooth micro porous to face visceral organs and other rough surface for tissue in-growth.

e - PTFE Microscopic view

Operating Factors Influencing Mesh Choice :

Targets & Dreams achieved!

REVIEW OF LITERATURE

Comparison of early outcomes for laparoscopic ventral hernia repair between nonobese and morbidly obese patient populations. Surg Endosc.2008 Oct;22(10):2244-50. Epub 2008 Jul 12.Ching SS, Sarela AI, Dexter SP, Hayden JD, McMahon MJ.

CONCLUSION: No significant difference in the incidence of peri operative complications or recurrence after LVHR was observed between the morbidly obese patients and the non-morbidly obese patients.

Management of ventral hernias during laparoscopic gastric bypass.Surg Obes Relat Dis. 2008 Nov-Dec;4(6):757-8.Datta T, Eid G, Nahmias N, Dallal RM.

The only predictor for an increased length of hospital stay was hernia repair with mesh (odds ratio 9.2, P = .002). The average follow-up was 14 months (range 4-30 months). Of the 8 patients who had undergone primary repair, 2 presented with a postoperative small bowel obstruction at the site of their VHR. None of the patients who underwent VHR with prosthetic mesh developed an obstruction or clinical evidence of recurrence or infection

Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/m2Surg Endosc 2007 Dec;21(12):2293-7. Raftopoulas I, Courculas AP

CONCLUSIONS: For morbidly obese patients, LVHR is safe and effective, but it is associated with higher likelihood of recurrence, and patients should be appropriately informed.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred.

Surg Endosc.2004 Feb:18(2):207-10 Schauer PR et al. CONCLUSION: Biomaterial mesh (SIS)

repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias.Newcomb WL, Polhill JL, Chen AY, Kuwada TS, Gersin KS, Getz SB, Kercher KW, Heniford BT.

2008 Oct;12(5):465-9

CONCLUSION: Gastric bypass prior to staged ventral hernia repair in morbidly obese patients with complex ventral hernias is a safe and definitive

CONCLUSION Concomitant repair of ventral hernia

with bariatric surgery is safe. Deferred treatment predisposes to higher complication rate.

Prosthetic repair is better than primary repair

Biological, dual, PTFE or other composite meshes can be safely used

In selected cases judicious use of surgeons discretion is warranted.


? SIMULTANAEOUS : WHEN : WHEN NOT ? NOT SIMULTANAEOUS : HERNIA FIRST : BARIATRIC FIRST WHEN IS THE RIGHT TIME FOR SECOND PROCEDURE TECHNIC : OPEN / LAP ANATOMICAL / MESH REPAIR PORT POSITION, PATIENT POSITION MESH CHOICE FIXATION DEVICE SPECIAL PRECAUTIONS TYPICALLY SIGNIFICANT SITUATION : HIATUS HERNIA / INT HERNIA DRAIN OR NOT ? DOES HERNIA INFLUENCE THE TYPE OF BA SX PROCEDURE TO BE DONE


? SIMULTANAEOUS : WHEN : WHEN NOT


? NOT SIMULTANAEOUS

: HERNIA FIRST : BARIATRIC FIRST


WHEN IS THE RIGHT TIME FOR SECOND PROCEDURE


ANATOMICAL when why

MESH REPAIR when why


MESH CHOICE

FIXATION DEVICE


SPECIAL PRECAUTIONS


TYPICALLY Special considerations :HIATUS HERNIA :INTERNAL HERNIA


DRAIN OR NOT ?


DOES HERNIA INFLUENCE THE TYPE OF BA SX PROCEDURE TO BE DONE

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challenges and management strategies of hernia in the obese

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