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VENTRAL HERNIA REPAIR BY
DR NIKHIL AMEERCHETTY MS GENERAL SURGERY RESIDENT
email : [email protected]
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Introduction Protrusion Through The Anterior Abdominal Wall Fascia.
1. Spontaneous 2. Acquired
Incisional Hernias Account For 15% To 20% Of All Abdominal Wall Hernias 4 Million Laparotomies Performed Annually 2% To 30% Incidence Of Incisional Hernia, 150,000 Ventral Hernia Repairs Are Performed Each Year.
Rucinski J, Closure of the abdominal midline fascia,Am Surg 67:421–426, 2001.
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ANATOMY
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Treatment: Operative Repair
Primary repair – recurrence rate of 10 – 50%
Mesh repair - recurrence rate of 5-25%
Wright BE, , Is laparoscopic hernia repair Am J Surg 184:505–508 Anthony T, Factors affecting recurrence , World J Surg 24:95–100, 2000.
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Choice of operation ?????
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COMPONENT SEPARATION TECHNIQUE
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Types
Open CST Laproscopic CST Endoscopic with open/laproscopic CST Anterior CST Posterior CST All the above with or without mesh reinforcement
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TECHNIQUE OF COMPONENT SEPERATION TECHNIQUE
D
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Abdominal Wall Reconstruction Utilizing the Component SeparationTechnique: Does Reinforcing Mesh Reduce Recurrences?
J Scott Roth*, Dennis F Diaz, Margaret Plymale and Daniel L DavenportDepartment of Surgery, University of Kentucky College of Medicine, Lexington, USA
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Introduction Incisional hernia Incidence 11-20% in patients undergoing laparotomy Primary suture based repair - high incidence of recurrence. Mesh for hernia repair improved recurrence rates . Laparoscopic hernia repairs not suited for 1. Loss Of Abdominal Domain,2. Infection 3. Abdominal Contamination.
Mudge M, Hughes (1985) Incisional hernia: a 10 year prospective study Br J Surg 72: 70-71. Cengiz Y, Israelsson LA (1998) Incisional Hernia 2:175-177.
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The Component Separation Technique (CST)
Ramirez and co-workers in 1990
Abdominal wall without the need for a synthetic mesh.
Autologous Tissue Transfer
Approximation Of The Rectus Abdominis Muscle Complex
Closure Of The Linea Alba Following Bilateral Release Of The External Oblique Aponeurosis And Posterior Rectus Sheath.
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Methods Institutional Review Board approval
surgical database at the University of Kentucky 2004 - 2009.
Chi square test, Fisher’s exact test, or ANOVA .
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Operative Reports Reviewed
Biologic Or Synthetic Mesh .
Demographic Data
Complications (Wound Infection, Wound Necrosis, Abscess, Seroma , Cellulitis)
Recurrences. ( Physical Examination Or Abdominal CT Scan) .
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Results
Total of 126 patients Median follow-up 15.6 months (1-36 month range).
The overall recurrence rate was 20.6%.
Wound complications were seen in 46%
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25.5 16.7 27.3
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46.0 20.6
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Conclusions Wound complications following CST are increased in patients with
obesity.
Hernia recurrence rates are similar between primary, recurrent, and multiply recurrent hernia repairs
Reinforcing CST hernia repairs with either biologic or synthetic mesh has no proven advantage over an unreinforced repair.
WC, van den Tol MP, de Lange DC, Braaksma MM, et al.(2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343: 392-398.
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Introduction
Very large incisional hernias defect of more than 10 cm .
The OCS gives an abdominal wall release of 10–15 cm on every side
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Endoscopic component separation
The ECS can be combined with other open or laparoscopic procedures
In 2007, Rosen et al.
Retrospective study of seven patients
The residual defect size 338 cm2 . ECS enabled tension-free primary fascial reapproximation in all
patients.
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Technique of ECS A bilateral 15-mm skin incision below the costal margin
10-mm balloon dilator is inserted.
Blunt dissection between the external and internal oblique muscle.
Fascia of the external oblique muscle is vertically incised
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Results
There was one superficial surgical site infection
No recurrences were identified.
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STUDY
Harth and colleagues Retrospective study 32 ECS to 22 OCS.
PARAMETRE ECS OCS
major wound morbidity (p=0.07)
19 % 41 %
recurrences rates (p=0.99) 27% 32%
Hospital length of stay (p=0.09)
8 11
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STUDY
Bilateral ECS combined with an open sublay repair in 23 patients
Defect size of 210 cm2 .
The abdominal wall release on each side was 2–6 cm.
All patients received large-pore PP mesh.
Follow up 21 months
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Complications
Hematoma 3
Lateral abdominal wall bulging 3
Superficial wound infection 1
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StatementsLevel 3
The ECS is feasible with low morbidity The ECS can be combined with lap IPOM, open IPOM, open sublay, and open onlay
technique in complex hernias Abdominal wall release after ECS is less extensive than after OCS There are fewer wound infections and wound healing problems after ECS compared
to OCS
Level 4
The question whether the lateral compartment should be augmented with mesh remains unresolved.
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Recommendations
Grade C In large and very large ventral and incisional hernias, the ECS
can be considered in combination with open or laparoscopic mesh techniques if the surgeon is able
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Methods
Medical records at Royal Liverpool Hospital from 2009 to 2012 were reviewed.
Patients were classified by the Ventral Hernia Working Group (VHWG) grading system.
Grade 1Low risk
Grade 2Comorbid
Grade 3 Potentially contaminated
Grade 4 Infected
No H/O wound infection Smoker Stoma present Infected mesh Obese Previous wound
infection Septic dihiscence
Diabetic Violation of gastrointestinal tract
Immunosuppressed
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Results Twenty-three patients’ (15 males, 8 females) .
Median age 57 years (range20-76 years).
Median follow-up at the time of review was 17 months (range 2-48 months).
There were 13 grade III hernias and 10 grade IV hernias
Wound infection (13%), superficial wound dehiscence (22%), seroma formation (22%) and stoma complications(9%).
Hernias have recurred in 3 patients (13%).
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Conclusions
Components separation and reinforcement with biological mesh is a successful technique in the grade III and IV abdomen with acceptable rate of recurrence and complications.
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Patients and methods
2006 and 2010,
Medical records analysed
Nine patients underwent the combination procedure.
Mean size of the transverse defect was 20 cm .
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Conclusion
Low recurrence rate in the short-term follow-up.
Increased occurrence of postoperative wound infections.
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Methods
75 patients over a 10-year period (2000 to 2010)
Adult patients (aged 18 to 75 years at the time of operation)
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Results
62% of recurrent hernias diagnosed within the first year
86% after a 2-year follow-up.
28% of recurrences were detected within 6 months
Hawn MT, Long-term follow-up . J Am Coll Surg 2010;210:
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Conclusions
Literature review CST without mesh shows low recurrence rates - underestimated
Author experience - high recurrence rate if follow up is more than a year
Mesh augmentation will decrease recurrences,
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Methods A single institutional retrospective review
42 patients ECS at a single institution by a single surgeon for ventral hernia repair with prosthesis from 2010 to 2013.
17 patients open ventral hernia repair (OHR)
25 laparoscopic ventral hernia repair (LHR).
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Conclusions ECS with laparoscopic fascial re-approximation had
Shorter operative time
Estimated blood loss
Wound complications similar in both groups
Increase hernia recurrences post-operatively in the laparoscopic group.
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Thank you