SYNOPSIS

Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka.

TOPIC:

“Clinical study and Management of Paraumbilical hernia in adults

in Rajarajeswari Medical College & Hospital”

NAME OF THE CANDIDATE: Dr. Shaziya Hassan Ali

GUIDE: Dr. S. Venkatesh MS (General Surgery)

COURSE AND SUBJECT: MS (General Surgery)

DEPARTMENT OF GENERAL SURGERY,

RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL,

BANGALORE - 560074

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Date: 29/10/2013

From,Dr. Shaziya Hassan Ali,

1st Year Post Graduate,

Department of General surgery,

Rajarajeswari Medical College and Hospital,Bangalore - 560074

To,The Co-ordinator,Ethical Committee,Rajarajeswari Medical College and Hospital,Bangalore - 560074

Subject: Ethical clearance for the study to be undertaken for dissertation.

Respected Sir/Madam,

With reference to the above subject, I am hereby submitting the synopsis for the study titled, “CLINICAL STUDY AND MANAGEMENT OF PARAUMBILICAL HERNIA IN ADULTS IN RAJARAJESWARI MEDICAL COLLEGE & HOSPITAL” to be conducted in Rajarajeswari Medical College and Hospital.

I wish to request the approval of the Institutional Ethical Committee for conducting the study as a dissertation.Thanking You,

Yours sincerely, Dr. Shaziya Hassan Ali

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKABANGALORE

ANNEXURE – IIPROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the candidate and address ( in block letters)

: DR. SHAZIYA HASSAN ALIDEPARTMENT OF GENERAL SURGERYRAJA RAJESWARI MEDICALCOLLEGEKAMBIPURA, MYSORE ROADBANGALORE – 560074KARNATAKA

Permanent address: ZAINABA MANZIL, NEAR C.M.L.P SCHOOL,

MATTOOL NORTH P.O, KANNUR DIST, KERALA – 670325

2 Name of the institution: RAJA RAJESWARI MEDICAL COLLEGE

KAMBIPURA,MYSORE ROAD,BANGALORE-560074

3 Course of study and subject : M.S. (GENERAL SURGERY)

4 Date of admission to the course

:29th MAY 2013

5 Title of Topic:

CLINICAL STUDY AND MANAGEMENT OF PARAUMBILICAL HERNIA IN ADULTS.

6 Brief Resume of the intended work6.1 Need for the study

Umbilical hernia is an abnormal protrusion of a viscus, or part of a viscus through a congenital or acquired defect. In adults, most umbilical hernias are in fact para-umbilical, with the defect arising just above or below the cicatrix.

It is more common for hernias to occur just above the umbilicus, where the tissue consists of a thin layer of transversalis fascia. Inferiorly, there is slightly more reinforcement in the form of the obliterated umbilical vessels. They can present in either the elective or emergency setting and the treatment can differ in each case.

Risk factors include: - Multiple pregnancies – Ascites (excess fluid in peritoneal cavity) – Obesity Cirrhosis Lifting heavy objects Having a persistent cough

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Although paraumbilical hernias are amongst the commonly occurring abdominal wall defects, not much work has been done to record the incidence. Studies quote an incidence of 3-8.5% among all types of hernias.

This study attempts to evaluate the incidence, clinical features, risk factors, operative techniques, and post operative course of paraumbilical hernias in adults admitted in Rajarajeshwari medical college.

Since women are the predominant cases, (sex ratio F:M = 5:1), paraumbilical hernias can cause distress to these patients not only because of their complications but also because of the cosmetic angle, this study to evaluate risk factors and management of paraumbilical hernias is thus well justified.

6.2 Review of Literature

The first references to umbilical hernia were recorded in the Egyptian Papyrus of Ebers (Circa 1552, B.C.), but the first formal description of umbilical hernias comes from the Hindu physician Charaka in his writings dated A.D. 1 or earlier. The ancient Jews also recognized umbilical hernias and treated them conservatively.1

Celsus, in the first century, A.D. treated umbilical hernias with an elastic suture, and Soranus (A.D. 98-117) described a technique of strapping.2

The first recorded description of umbilical hernia repair comes from Albucasis, Abul Qasim al Zahrawi, the great Moorish Surgeon (A.D. 1013-1106).3

Antonio Benivieni (1443-1502) probably was the first to treat an incarcerated hernia in a child; he ligated the hernia. Once the mortified flesh fell off, the child “regained perfect health”.4

In 1737, Queen Caroline of England had an incarcerated hernia that eventually was lanced to permit drainage of intestinal matter. She succumbed to her illness, however, because surgical treatment had been delayed for 3 days while she was treated with polypharmacy, enemas, aperients, and bleeding, illustrating the need for timely surgical intervention.4

In his ‘Anatomy of the Human body’, published in 1740, William Cheselden describes a patient with an incarcerated hernia whom he amputated the protruding mass of “mortified bowel and left the end of the sound gut hanging out of the navel to which it after wards adhered : she recovered and lived many years after, voiding excrement through the intestine at the navel’.4

The incidence of incarceration of umbilical hernias in adults is 14 times that in children. There is a large sex difference with over 90% occurring in women and almost all are obese and multiparous. In this patient population, umbilical hernias incarcerate half as often as inguinal hernias and 3 times more often than femoral hernias.5

William J Mayo aptly said “this form of hernias has been the hardest to cure. Usually found in very corpulent people with small muscular development, the conditions are naturally unfavourable”, in his classic paper on Aug. 4 th, 1898 presented before the American Academy of Rail Road Surgery. He subsequently

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published it in the Annals of surgery 1899. In this paper he instituted his classical technique of overlapping fascia for the repair of hernia.5

Askar believes that variations in decussation of aponeurotic fibres in the midline have a role in the occurrence of umbilical and paraumbilical hernias.6

There also appears to be a 9% to 12% familial predisposition to umbilical hernias, but no genetic pattern of inheritance has been identified.7,8

A retrospective review of adults with umbilical hernias found that only 10.9% recalled having hernias from childhood. It also suggested that those fascial defects greater than 1.5 cm persisted into adult life.9

In a separate series of 71 women and 82 men, it was noted that only 2 women had recurrence of their infantile umbilical hernias and this occurred during pregnancy. None of the men followed developed recurrence.10

Classically, repair was done, using the vest-over-pants approach proposed by Mayo, but because of increased tension on the repair and recurrence rates of almost 30% with long term follow-up, the mayo repair is rarely performed today. Instead, small defects are closed primarily after separation of the sac from the overlying umbilicus and the surrounding fascia. Defects greater than 3cm are closed using prosthetic mesh.11

Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, upto 54% for simple suture repair are reported. In total 131 consecutive patients underwent operative repair of umbilical hernia, fourteen umbilical hernia recurrences were noted, none had been repaired using mesh. Recurrence rates of 1% are reported for mesh repair.12

There is no consensus on the best technique for the repair of umbilical hernia in adults. Laparoscopic onlay patch hernioplasty is a safe and efficacious technique for the repair of umbilical hernia. Compared to Mayo repair the laparoscopic approach confers the advantages of reduced postoperative pain, shorter hospital stay, and a diminished morbidity rate.13

Attention needs to be paid to the development of umbilical hernias after laparoscopic trocar insertion. All trocar sites larger than 10 mm should be properly closed after operation.14

Umbilical hernia repair can be carried out safely and securely under local anaesthesia with a tension-free mesh technique (cone or a sublay patch) with a low morbidity, negligible recurrence rate, and a high degree of patient satisfaction. It should be the procedure of choice for all such hernias.15

The preperitoneal laparoscopic technique for umbilical hernia repair combines the advantages of a laparoscopic, minimally invasive approach, avoiding the potential complications related to intraabdominal mesh position.16

6.3 Objectives of the studyThis is a clinical study which evaluates the clinical features, risk factors, operative techniques and post operative outcome of paraumbilical hernias in adults.

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7 Materials and methods7.1 Source of data

It will include patients admitted with paraumbilical hernias to the surgical wards of Rajarajeshwari Medical College between 1st December 2013 to 30th June 2015.

7.2 Methods of collection of data ( including sampling procedure, if any)

A proforma drafted for the study of all patients with paraumbilical hernias will be used.

All cases of paraumbilical hernias admitted to the surgical wards of Rajarajeshwari Medical College during the study period will be including in the study.

INCLUSION CRITERIA All patients above the age of 18 admitted with paraumbilical hernia (obstructed/ strangulated/complicated)

EXCLUSION CRITERIA All patients below 18 years.

FOLLOW UPFollow up of the patients will be done after one week, one month and 6 months from the date of operation.

STATISTICAL ANALYSISDescriptive analysis will be used to present the data.

7.3Does the study require any investigation or intervention to be conducted on patients or other humans or animals? if so please describe briefly.Yes,Routine :Hb, BT, CT, RBS, URINE ROUTINE, B. UREA, S. CREATININE, ECG, CHEST-X-RAYSpecial : USG – Abdomen

7.4 Has ethical clearance been obtained from your institution in case of 7.3 ?

Yes

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List of References

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1. Olch PD, Harkins HN. Historical survey of treatment of inguinal hernia. In : Nyhus LM, Harkins HN, eds. Hernia. Philadelphia : JB Lippincott Co., 1964:1.

2. Walker SH. The natural history of umbilical hernia. A six year follow-up of 314 negro children with this defect. Clin Pediatr (Phila) 1967; 6: 29-32.

3. Albucasis. On surgery and instruments. A definitve edition of the Arabic text with English translation and commentary by MS Spink and GL Lewis. London : The Wellcome Institute of the History of Medicine and Oxford. The University press, 1973.

4. Ellis H. The umbilical hernia of Queen Caroline. Contemp Surg 1980; 17: 83.

5. Mayo WJ. An operation for the radical cure of umbilical hernia. Ann Surg 1901; 34: 276.

6. Askar OM. Aponeurotic hernias. Recent observations upon epigastric and paraumbilical hernias. Surg Clin North Am 1984; 64: 315.

7. Cullen TS. Embryology, Anatomy and diseases of the umbilicus together with diseases of the urachus. Philadelphia : WB Saunder, 1916: 1.

8. Radhakrishnan J. Umbilical hernia. In : Nyhus LM, Condon RE, Eds. Hernia, 4 th ed. Philadelphia : JB Lippin Cott Co., 1995; 361.

9. Jackson OJ, Moglen LH. Umbilical hernia : A retrospective study. Calif Med 1970; 113: 8.

10. Sibley WL III, Lynn HB, Harris LE. A 25 year study of infantile umbilical hernia. Surgery 1964; 55: 462.

11. Arroyo A, Garcia P, Perez F, et al. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg 2001; 88: 1321-1323.

12. Halm JA, Heisterkamp J, Veen HF, Weidema WF. Long term follow up after umbilical hernia repair : are there risk factors for recurrence after simple and mesh repair. Hernia 2005; 9: 334-337.

13. Lau H, Patil NG. Umbilical hernia in adults. Surg Endoscopy 2003; 17(12): 2016-20.

14. Velasco M, Garcia Urena MA, Hidalgo M, Vega V, Larnero FJ. Current concepts on adult umbilical hernia. Hernia 1999; 3(4): 233-239.

15. Kurzer M, Belsham PA, Kark AE. Tension free mesh repair of umbilical hernia as a day case using local anaesthesia. Hernia 2004; 18(2): 104-107.

16. Denise E. Hilling, Linetta B. Koppert, Richar Keijzer, Laurents PS, Stassen and Hok J. Oei. Surgical Endoscopy 2009; 23(8): 1740-1744.

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CONSENT FORM / ಸಮ್ಮತಿಪತ್ರ

Thesis Topic: “CLINICAL STUDY AND MANAGEMENT OF PARAUMBILICAL HERNIA IN ADULTS IN RAJARAJESWARI MEDICAL COLLEGE& HOSPITAL, BANGALORE”.

MS Candidate: Dr. Shaziya Hassan Ali

Guide: Dr. Venkatesh

I/We have been explained about the study “CLINICAL STUDY AND MANAGEMENT OF PARAUMBILICAL HERNIA IN ADULTS IN RAJARAJESWARI MEDICAL COLLEGE& HOSPITAL” and also about the purpose of the study.

The medical data of our patient will be taken for the study only after obtaining the consent. I/We have been explained that the treatment of our patient is not affected by this study. I/We can refuse to give consent for inclusion of the patient into the study or can withdraw from the study anytime. I/We have been assured that there will not be any change in the treatment of the patient even if we refuse to give consent or withdraw from the study. I/We have also been assured that the privacy of the patient data will be maintained.]

ನಮಗೆ “CLINICAL STUDY AND MANAGEMENT OF PARAUMBILICAL HERNIA IN ADULTS IN RAJARAJESWARI MEDICAL COLLEGE & HOSPITAL” ಅಧ್ಯಯನಮತ್ತು�ಅದರಉದ್ದ�ೇಶದಬಗೆ�ತಿಳಿಸಿರ್ತುತ್ತಾ�ರೆ.

ಈಅಧ್ಯಯನಕ್ಕೆ�ನಮ್ಮರೋ� ಗಿಯವೈ�ದ್ಯಕೀ ಯಮಾಹಿತಿಯನ್ನು�ನಮ್ಮಸಮ್ಮತಿಯನ್ನು�ಪಡೆದನಂತರಉಪಯೋ ಗಿಸಲಾಗ್ನುವುದ್ನು.ಈಅಧ್ಯಯನದಿಂದನಮ್ಮರೋ� ಗಿಯಚಿಕೀತ್ಸೆ'ಯಲ್ಲಿ)ಯಾವುದೇ ಬದಲಾವಣೆಯಾಗ್ನುವುದಿಲ).ನಾವುಈಅಧ್ಯಯನಕ್ಕೆ�ನಮ್ಮರೋ� ಗಿಯವೈ�ದ್ಯಕೀ ಯಮಾಹಿತಿಯನ್ನು�ಬಳಸಲ್ನುಸಮ್ಮತಿನೀ ಡದೇಇರಬಹ್ನುದ್ನುಅಥವಾಯಾವುದೇ ಸಮಯದಲ್ಲಿ)ಅಧ್ಯಯನಕ್ಕೆ�ಸಮ್ಮತಿಯನ್ನು�ನೀರಾಕರಿಸಬಹ್ನುದ್ನು.ಸಮ್ಮತಿನೀ ಡದೇ ಇದ್ದಲ್ಲಿ)ಅಥವಾಅಧ್ಯಯನಕ್ಕೆ�ಸಮ್ಮತಿಯನ್ನು�ನೀರಾಕರಿಸಿದಲ್ಲಿ)ನಮ್ಮರೋ� ಗಿಯಚಿಕೀತ್ಸೆ'ಯಲ್ಲಿ)ಯಾವುದೇ ಬದಲಾವಣೆಯಾಗ್ನುವುದಿಲ)ವೈಂಬಆಶಾ?ಸನೆನೀ ಡಿರ್ನುತಾCರೋ. ನಮ್ಮರೋ� ಗಿಯಮಾಹಿತಿಯಗೌಪ್ಯತ್ಸೆಯನ್ನು�ಕಾಪಾಡಲಾಗ್ನುವುದ್ನು.

PATIENT SIGNATUREDATE

PROFORMA

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Name D.O.A.

Age D.O.D

Sex D.O.O

IP No. Unit

Occupation

Chief Complaints:

Present History:

Swelling: Site, Duration, Mode of onset, Progression, Disappearance on lying down

Pain : Site, Duration, Character, Radiation, Aggravating factors, Relieving factors, Vomiting / Nausea

Cardinal symptoms of intestinal obstruction – colicky abdominal pain, vomiting, abdominal distension, absolute constipation

Past History:Multiple pregnancies, ascites, obesity, cirrhosis, persistent cough

Personal History:Family History:Menstrual History:Treatment History: H/O Any drug intake

General Examination:Temp :Pulse Rate :Blood Pressure

Examination of abdomen:Inspection and Palpation of the swellingLiverGBSpleenRenal DiseaseColonic motility disorder

Investigations:

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Blood : Hb %CBCTC DC ESRPT, INRBT, CTBlood SugarUreaSerum Creatinine

LFT Chest Xray USG Abdomen

Operative Details:Open or laparoscopic methodOperative findings

Post Operative Period Complications:Pain using universal pain chartBleedingWound infectionMobilityRemoval of SutureTotal period of stay

Follow Up: After one month

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PAIN QUALITY ASSESSMENT SCALE© (PQAS©)

Instructions: There are different aspects and types of pain that patients experience and that we are

interested in measuring. Pain can feel sharp, hot, cold, dull, and achy. Some pains may feel like they

are very superficial (at skin-level), or they may feel like they are from deep inside your body. Pain can

be described as unpleasant and also can have different time qualities.

The Pain Quality Assessment Scale helps us measure these and other different aspects of your pain.

For one patient, a pain might feel extremely hot and burning, but not at all dull, while another patient

may not experience any burning pain, but feel like their pain is very dull and achy. Therefore, we

expect you to rate very high on some of the scales below and very low on others.

Please use the 20 rating scales below to rate how much of each different pain quality and type you may or may not have felt OVER THE PAST WEEK ON AVERAGE.

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INSTITUTIONAL ETHICS COMMITTEE

CERTIFICATE

The institutional ethical committee of Rajarajeshwari Medical College and Hospital,

Bangalore has approved the dissertation topic “CLINICAL STUDY AND

MANAGEMENT OF PARAUMBILICAL HERNIA IN ADULTS IN RAJARAJESWARI

MEDICAL COLLEGE & HOSPITAL” at Rajarajeswari Medical College and Hospital by

Dr. Shaziya Hassan Ali, postgraduate student in the Department of General surgery .

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