emergency treatment of complicated incisional hernias

8/10/2019 Emergency Treatment of Complicated Incisional Hernias

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Emergency treatment of

complicated incisional

herniasDesy Andriani


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Background

Incisional hernia is a seriouscomplication after abdominal surgery

which occurs in 11-23% of laparotomies.


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The emergency treatment of incisional

hernias is infrequent but it can be complicated

with strangulation or obstruction and in somecases the surgical approach may also include

an intestinal resection with the possibility of

peritoneal contamination.


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Since January 1999 till July 2008, 89

patients (55 males and 34 females) were

treated for complicated incisional

hernias in emergency.


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The patients were divided in two groups:

Group I consisting of 33 patients that were

treated with prosthesis apposition and GroupII, consisting of 56 patients that were treated

by performing a direct abdominal wall muscles

suture


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Results


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As concerns the group treated with the apposition of

prosthesis (Group I), obstruction with no possibility of

reduction occurred in 27 cases.

in these cases we performed an adhesiolisis and a

greater omentum resection (14 patients) which eased

the abdominal replacement of the ileal ansae, being

the omentum often inflamed, thickened and fibrous.


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In the remaining 6 cases, strangulation was the

reason for an emergency treatment; in these

cases we performed a resection of the necrotic

ileum and the intestinal continuity was restored

by carrying out a mechanic suture.

Strangulation occurred in those patients whose

incisional hernias had a narrow neck.


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In the patients treated with a direct abdominal

wall muscles suture (Group II) we carried out an

adhesiolysis and a greater omentum resection in

41 patients.

In 15 cases we performed a resection of the

necrotic ileum followed by a mechanic suture.


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As concerns the group treated with the apposition of

prosthesis (Group I), We registered 7 complications : 4

parcellar cutaneous necrosis, 2 hematomas and 1 wound

suppuration.

In the patients treated with a direct abdominal wall

muscles suture (Group II), We registered 24 complications;

7 parcellar cutaneous necrosis, 6 hematomas and 11 wound

suppurations


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All the patients underwent a 6-month follow up; we

noticed 9 recurrences (9/56, 16%) in the patientstreated with direct abdominal wall muscles suture and

1 recurrence (1/33, 3%) in the group of patients treated

with the prostesis apposition


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Discussion

Incisional hernias can range in size from very

small to large and complex ones and appear as a

bulge by the area of a previous surgical scar.

Surgical repair of incisional hernias is usually

recommended, as they can become a medical or

surgical emergency.


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An incisional hernia can be defined as complicated when

the involved structures undergo worsening conditions.

Particularly, the concerned structures may be described as

follows:

1) Cutaneous: large and thin scars, cutaneous atrophy

and eczemas, suppurative flogosis, fistulae.


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2)Hernial sac: multiple sacs, fibrous septa, sac

thickening and adhesions.

3)Visceral: chronic incarceration, obstruction,

strangulation, ileum and colonic torsion with

progressive damage up to gangrene; greater

omentum involvement, mesenteritis andperivisceritis


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The frequency of complicated incisional hernias varies

from 10 to 40%. The most frequent complications are

incarceration, obstruction and strangulation.

There are two main factors for the pathogeneses of these

complications: the hernial orifice rigidity and the presence

of tenacious adhesions between the hernial sac and its

content or between the sac and the surrounding tissues.


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At the moment the most frequent

treatment of voluminous incisional hernias

is performed through the use of syntheticprosthesis, which allows the abdominal wall

reconstruction according to the "tension

free" technique.


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The prosthesis is to be placed between

the peritoneum and the posterior surface

of the rectus abdominis muscles or

between the posterior surface of the

rectus abdominis muscles and their

posterior sheath.


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Conclusions

According to our experience, the emergency

treatment of complicated incisional hernias

through prosthesis apposition is always feasible

and ensures less post-operative complications

(16% vs 21,2%) and recurrences (3% vs 16%)

compared to the patients treated with direct

muscular suture


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THANK YOU

emergency treatment of complicated incisional hernias

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