current management of incisional hernia
DESCRIPTION
types of mesh available and principles of mesh repair for incisional hernia, why we should use mesh and if so what mesh and where to placeTRANSCRIPT
Endoscopy Conclave One Day Live Endoscopic Workshop & CME
01.09.2013Sunday, 8am-6pm
AC Auditorium-Level V@ Lotus hospital, Erode
Hosted byIMA TN SB- AMS Wing
IMA Erode BranchASI Erode City Chapter
Delegates: Rs:1000/- Postgraduates: Rs: 500/-
Morning Session: ( 8am-1`pm)•Live Endoscopy workshop: Basic
Diagnostic/ Banding of Varices/SclerotherapyDilatation of Stricture esophagus
•10 min Lectures on ‘Endoscopic Practice Guidelines ‘Endoscopic management of Corrosive stricture: When and How?:Management of variceal bleeding: Before and after endotherapy:Role of endoscopy in Upper GI malignancyFB esophagus:
•Live Endoscopy Workshop: AdvancedStent deployment/Glue Injection of Fundal varicesPolypectomy
•‘Futuristic’ Lectures: Tomorrow’s World of EndoscopyWhy surgeons should always be doing endoscopy?:Endoscopy in the era of Laparoscopy:
•Endo quiz:Post Lunch Session(2-4pm)•Panel Discussion: Team approach in the management of GI disorders:
GERD, Achalasia, Upper GIBleeding , Bile duct stones, •Live Colonoscopy/ERCP Workshop
Colonoscopic polypectomyBile duct stone removal/StentingPancreatic endotherapy
•Challenging situations for endoscopistUpper GI bleeding with normal endoscopy: How to proceed?:Difficulty reaching caecum during Ccolonoscopy : Tricks of the Trade:
Post Tea Session( 4-6pm)•Humour in Gastroenterology•Convocation and Award Ceremony at 4.30pm
CURRENT MANAGEMENT OF INCISIONAL HERNIA
Dr.S.EaswaramoorthyDr.TC.GnanasekaranDr.KV.Durairaj
ASI Erode City Branch
PROF.JR.SANKARAN SYMPOSIUM@ TN&P ASICON 2013
Symposium on Management of Incisional hernia. Dr.S.Easwaramoorthy 20min
Pathogenesis of Incisional hernia Prevention of incisional hernia Evaluation and Current management of incisional
hernia All, we should know about Mesh for hernia!
Dr.T.G.Gnanasekaran 15min Open mesh repair and abdominoplasty
Dr.K.V.Durai raj 15min Laparoscopic mesh repair of incisional hernia
Case scenarios and discussion 10min
Why it happens?...
Incisional HerniaWhy it happens?
Patient factorsSurgeon factors
Disease factors
Patient Factors
Obesity Diabetes Renal Failure Anaemia and
Hypoproteinemia Post Operative Chest
Infection
Disease Factors
Peritonitis Visceral Cancer/ascites Colostomy
Surgeon’s Factors
Incision Low midline/ Subcostal
Drain/Stoma Wound Protection Suturing Technique
Suturing Technique
Type of Suture material Absorbable :
Vicryl/PDS/Dexon Non absorbable :
Nylon/Prolene/Ethibond
Size of Suture Technique of Suturing
Peritoneum?1 cm across and 1 cm apartRule of 4
Clinical Assessment
Lying Standing
Loss of Abdominal Domain
Role of Imaging in Incisional Hernia
CT Abdomen
How to manage Incisional hernia?
Open procedure (with Abdominoplasty) Anatomical Repair Component Separation technique Mesh repair
Sublay, Inlay, Onlay
Laparoscopic repair IPOM
How to manage Incisional hernia?
Open procedure (with Abdominoplasty) Anatomical Repair Component Separation technique Mesh repair
Laparoscopic repair Mesh repair
Mesh is a must…
Why Mesh?
Low recurrence rate Inguinal hernia repair
Bassini’s repair : 10% Shouldice repair : 1% Lichtenstein’s Mesh repair : <1%
Ventral hernia Suture Vs Mesh: : 50% Vs 10%
Tension free & Pain free Quick recovery Quick to learn and easy to do!
Why Mesh?Pathogenesis of Hernia Defective Collagen
Reduced ratio of type I and type III collagen Type I: Mature Collagen, strong and normal tissue Type III: Immature Collagen, weak, in healing wounds Type I : Type III ratio normally is 4:1
Connective tissue pathology is not only a cause of primary herniation but its presence can prevent cure!
Increased matrix metalloproteinase activity(MMP)
‘Understand the Wound Biology’
A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia?Raphael Rosch, Uwe Klinge, Zhongyi Si, Karsten Junge, Bernd Klosterhalfen, and Volker Schumpelick, BMC Med Genet. 2002; 3: 2.
Lichtenstein’s Mesh Repair
Tension Free repair• Under LA• Day care• Low recurrence rate!
Billroth’s Vision
‘‘If we could artificially produce tissues of the density and toughness of fascia and tendon the secret of the radical cure of hernia wouldbe discovered’’.
- Beitrage zur Chirurgie (1878)
Inventor of Prosthetic Mesh repair: Dr. Francis Usher (1908-1980)
• Inventor of Polyehylene(Marlex) and Polypropylene mesh• Several Animal studies about their inertness• 20 papers• Innovative ways of placing the meshes: Inlay, Overlay, Sandwich tech etc
Stoppa’s Mesh Repair
Pre peritoneal Mesh Over Myopectineal Orifice
GPRVS
‘‘In the adult, repairinginguinal hernias in the inguinal canal and femoral herniasin the femoral canal is like closing the curtain insteadof shutting the window’’
Mesh repair of Incisional Hernia
Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications
Types of Mesh Synthetic Mesh
Non absorbable Polyprophylene(Prolene) Polyethylene(Marlex) Polyester(Dacron) PTFE (Teflon/Gordex)
Absorbable Vicryl
Combined Vipro
Synthetic with Absorbable Barrier( Dual mesh) Parietex Proceed Etc
Biological Mesh Surgisis ( Porcine submucosa) Alloderm (Cadaveric human dermis)
What MeshLight weight Vs Heavy weight?
Light weight Mesh Heavy weight Mesh
Definition?
Light wt, thin fibres, macro pores (>1.5mm)Less amt of FB
Heavy wt, thick fibres, micro pores (< 1.5mm)So more amount of FB
Qualities FlexibleLess FB reaction and pain
StifferMore FB reaction and pain(Problem of adhesion, fistula)Shrinks moreStronger! - so what
Examples Ultrapro, Vipro Marlex, Dacron, PTEF
The lightweight and large porous mesh concept for hernia repair.Klosterhalfen B, Junge K, Klinge U. Expert Rev Med Devices. 2005 Jan;2(1):103-17.
Laparoscopic Ventral Hernia RepairChoice of Composite Mesh
Name Parietal side Visceral Side Longevity
Remarks By
Parietex Polyester Atelocollagen, PEG, Glycerol
20 days
expensive Covidien
Proceed Polypropylene
Oxidised (ORC) regenerated cellulose/PDS
30 days
Ethicon
Sepramesh
PP PGA/Hydrogel
30 days
Davol
C QUR PP Omega 3 FA Atrium
Pro VISC 160
Polyester Polyurethane Life Cost effective
Lotus
Dual Mesh e PTFE (rough)
e PTFE(smooth)
Life Gore
Kugel/Composix
PP(HW) e PTFE Life Cann’t trim Bard
Parietex Mesh
Features:
Polyester with Collagen cover on the visceral side
No adhesion or infection
Handles well during Lap
Holds sutures well Can be trimmed
Moreno-Egea A, Liron R Girela E, Aguayo JL. Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience. 2001 Surg Laparoc Endosc Percutan Tech Apr;11(2):103-6
Proceed Mesh (Ethicon) Parietal Side
PP(LW) encapsulaed in PDS Blue stripped side
Visceral Side ORC ( Oxidised regenerated
cellulose)
Macroporous Conforms to anatomy Can be trimmed
Downside: Ensure meticulous
hemostasis
or else adhesions likely Shrinks by 30% Delamination and seroma
Proceed Mesh (Ethicon)Time line
1 week
2 weeks
Day 1
3 months
Pro VISC 160
Polyester White Parietal side
Polyurethane Blue smooth visceral
side
With Sutures Pre cut in various
sizes
Parietal side: PPVisceral side: e PTFE
Bard (Composix) Gore Dual Mesh
Parietal side: Rough PTFEVisceral side: smooth PTFE
Mesh repair of Incisional Hernia
Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications
Where to place the Mesh?On Lay In Lay
Under Lay IPOM
Pascal’s Hydrostatic Principle
Onlay Vs Inlay
Effect of Intra abdominal Pressure
Choose a mesh at least 5cm larger than the defect all
round.
Mesh repair of Incisional Hernia
Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications
Mesh Fixation Methods…
AbsorbaTack (Covidien)
Permasorb (Davol / Bard )
Fibrin sealant
Spiral Tackers
Staples
Fibrin Glue
Suture
Trans Facial Suture Fixation
Ideal Fixation Method
No Type of Fixation
Features
1 Trans Fascial suture fixation
Chronic pain
2 Suturing 2cm apart
3 Spiral Titatinum Tackers
2cm apartDouble crown techniqueNerve entrapment, adhesion, rarely tacker hernia
4 Absorbable tackers
For initial 1 year
5 Fibrin Glue Suitable for inguinal hernia? Ventral Hernia: Alternative or Adjunct: needs trial.
Closure of Hernia defect to avoid mesh protrusion or displacement
To with stand the intra abdominal tangential force and also shearing Force due to abdominal muscle contraction
Mesh repair of Incisional Hernia
Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications
Mesh Related Complications…
Infection Surgeon’s nightmare
Intestinal adhesions Composite mesh for laparoscopic ventral hernia repair
Bowel obstructions
Erosion of the prosthesis into the adjacent hollow viscus
Contraction of prosthesis At least 5cm larger than the size of the defect
Prevention of Mesh infectionConsider
Patient factors Smoking DM Obesity Re operation Big incision
Type of Mesh Macroporous vs microporous Impregnated mesh
Technique Lap Vs Open On lay Vs In lay
Prophylactic antibiotics Avoid unplanned
enterotomy Infected field
Absorbable mesh Biological mesh
Ventral hernia repair•Risk of infection is 3-10% in Open mesh repair•Risk of infection is < 1% in Lap Mesh repair
Conclusion
Mesh repair of abdominal wall hernia is the Standard of Care.
Composite mesh has to be used for ventral hernia
Avoid Mesh related complications , if possible
Next
Dr.T.G.Gnanasekaran 15min Open mesh repair and abdominoplasty
Dr.K.V.Durai raj 15min Laparoscopic mesh repair of incisional
hernia Case scenarios and discussion
10min
•21year old lady,•Para 1•Large Incisional hernia following
c-section•Yet to complete her family
•Surgery Vs Conservative treatment•Pregnancy after a mesh repair•Mesh repair during C-section
Case 1
•40 year old obese lady•Abdominal hysterectomy 5 years ago•Incisional Hernia in Lower midline scar•Has Symptomatic Gall stones
•Open /Laparoscopic/Combined
Case 2
•35 year old lady•Laparoscopic hysterectomy 6 months ago•Umbilical Port site Hernia
•Why?•Suture Vs Mesh?
Case 3
Endoscopy Conclave One Day Live Endoscopic Workshop & CME
01.09.2013Sunday, 8am-6pm
AC Auditorium-Level V@ Lotus hospital, Erode
Hosted byIMA TN SB- AMS Wing
IMA Erode BranchASI Erode City Chapter
Delegates: Rs:1000/- Postgraduates: Rs: 500/-
