Health-Process-Evidence-based Clinical Practice Guidelines on Incisional Hernias

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Health-Process-Evidence-based Clinical Practice
Guidelineson Incisional Hernias

• by
• Michael Angelo L. Suñaz, M.D.
• Department of Surgery
• Ospital ng Maynila Medical Center

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Clinical Questions

• What is an operational concept of hernias?
• Ans
• a protrusion of a viscus through an opening in
  the wall of the cavity in which it is contained.

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Clinical Questions

• 2. What are the general categories of hernia?
• Ans
• Groin Hernias
• Abdominal Wall Hernias
• Perineal Hernias
• Intraabdominal Hernias
• Diaphragmatic Hernias

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Clinical Questions

• 3. What are the sub-categories of groin hernias?
  
• Ans
• Inguinal Hernias
• - direct
• - indirect
• Femoral Hernias

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Clinical Questions

• 4. What are the sub-categories of abdominal wall
  hernias?
• Ans
• Incisional Hernias
• Peristomal Hernias
• Omphalocele
• Gastroschisis
• Umbilical Hernias

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Clinical Questions

• 4. What are the sub-categories of abdominal wall
  hernias? (contd)
• Ans
• Epigastric Hernias
• Spigelian Hernias
• Interparietal Hernias
• Supravesical Hernias
• Lumbar Hernias

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Clinical Questions

• 4. What are the sub-categories of abdominal wall
  hernias? (contd)
• Ans
• Obturator Hernias
• Sciatic Hernias

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Clinical Questions

• 5. What are the sub-categories of perineal
  hernias?
• Ans
• Perineal Hernias
• Prolapse of the Rectum

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Clinical Questions

• 5. What are the sub-categories of intraabdominal
  hernias?
• Ans
• Mesenteric Hernias
• Retroanastomotic Hernias
• Paraduodenal Hernias
• Hernias of the Broad Ligament

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Clinical Questions

• 6. What are the sub-categories of diaphragmatic
  hernias?
• Ans
• Paraesophageal Hiatal Hernias
• Congenital Diaphragmatic Hernias
• Traumatic Diaphragmatic Hernias

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Clinical Questions

• 6. What is an operational concept of incisional
  hernias?
• Ans
• any abdominal wall gap in a previous incision
  site, with or without a bulge, that is
  perceptible on clinical examination or imaging by
  1 year after the index operation.

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Clinical Questions

• 7. What are reliable symptoms and signs (more
  than 90 certainty) that will indicate that a
  patients has an non-incarcerated incisional
  hernia?
• Ans on and off abdominal mass
• (with a concurrent abdominal wall gap in a
  previous incision site perceptible by imaging or
  physical examination by 1 year after the index
  operation)

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Clinical Questions

• 8. What are reliable symptoms and signs (more
  than 90 certainty) that a patient has
  incarcerated incisional hernia?
• Ans
• Abdominal mass
• Abdominal pain/tenderness over the defect,
  greatest along the fascial margins
• Irreducible
• (with a concurrent abdominal wall gap in a
  previous incision site perceptible by imaging or
  physical examination by 1 year after the index
  operation)

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Clinical Questions

• 9. What are reliable symptoms and signs (more
  than 90 certainty) that a patient has
  strangulated incisional hernia?
• Ans
• Abdominal mass
• Severe Abdominal pain/tenderness over the
  defect, greatest along the fascial margins
• Redness over the defect
• Irreducible
• (with a concurrent abdominal wall gap in a
  previous incision site perceptible by imaging or
  physical examination by 1 year after the index
  operation)

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Clinical Questions

• 10. If an incisional hernia does not present
• with a bulge, how is it diagnosed?
• Ans
• Detection of a defect in a previous incision
  site through physical examination

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Clinical Questions

• 11. If a paraclinical diagnostic procedure is
  needed in a patient with suspected incisional
  hernia, what is the most cost-effective
  procedure?
• Ans
• -abdominal ultrasound

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Clinical Questions

• 12. How are incisional hernias classified?
• Ans
• I. According to localization (modified
  Chevrel)
• Vertical
• 1.1. Midline above or below umbilicus
• 1.2. Midline including umbilicus right or left
• 1.3. Paramedian right or left
• Transversal
• 2.1. Above or below umbilicus right or left
• 2.2. Crossed midline or not

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Clinical Questions

• 12. How are incisional hernias classified?
  (contd.)
• Ans
• - Oblique
• 3.1. Above or below umbilicus right or left
• - Combined (midline oblique midline
  parastomal etc)

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Clinical Questions

• 12. How are incisional hernias classified?
  (contd.)
• Ans
• II. According to size
• Small (lt5 cm in width or length)
• Medium (5-10 cm in width or length)
• Large (gt10 cm in width or length)

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Clinical Questions

• 12. How are incisional hernias classified?
  (contd.)
• Ans
• III. According to recurrence
• Primary incisional hernia
• Recurrence of an incisional hernia (1., 2., 3.,
  etc. with type of hernioplasty adaptation,
  Mayo-duplication, prosthetic implantation,
  autodermal etc.)

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Clinical Questions

• 12. How are incisional hernias classified?
  (contd.)
• Ans
• IV. According to the situation at the hernia
  gate
• Reducible with or without obstruction
• Irreducible with or without obstruction

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Clinical Questions

• 12. How are incisional hernias classified?
  (contd.)
• Ans
• V. According to symptoms
• Asymptomatic
• Symptomatic

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Clinical Questions

• 13. What are the common causes of incisional
  hernias?
• Ans
• 1. poor surgical technique
• 2. use of rapidly degraded absorbable
  suture materials
• 3. closure of the abdomen under tension
• 4. infection

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Clinical Questions

• 13. What are the common causes of incisional
  hernias?(contd).
• Ans
• 5. Male sex
• 6. advanced age
• 7. morbid obesity
• 8. abdominal disstention
• 9.cigarette smoking
• 10.pulmonary disease
• 11.hypoalbuminemia

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Clinical Questions

• 13. What are the goals of treatment of
  incisional hernias?
• Ans
• - reduce hernial content
• - repair the fascial defect
• - prevent recurrence of incisional hernia
• after the repair

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Clinical Questions

• 14. What are the treatment options for incisional
  hernias?

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Non-surgical (binders, corsets) gtMay be used pre-operatively to TEMPORARILY reduce large necked hernias of high risk patients gtno repair of fascial defect Injury to skin or bowel due to the pressure may mask signs of incarceration or strangulation P500-1000 available
Surgical gtreduction of hernial content gtrepair of fascial defect Up to 50 recurrence rate with 5 prosthesis related infection rate OR cost 6,000-40,000 available

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Open Surgery gtreduction of hernial contents gtrepair of hernial defect gtWider incision gtmore invasive gtlonger recovery time OR cost P6000 (if with prosthesis) Readily available
Laparoscopic Surgery gtreduction of hernial contents gtrepair of hernial defect gtsmaller incision gtless invasive gtshorter recovery time OR cost P40000 Not readily available

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Simple non-prosthesis repair gtreduction of hernial contents gtrepair of hernial defect 25-55 recurrence rate1 OR cost available
Incisional herniorrhaphy with mesh gtreduction of hernial contents gtrepair of hernial defect 1-20 recurrence rate Prosthesis-related infection (5) 2 OR cost P6,000 available

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TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
Onlay prosthetic repair gtreduction of hernial contents gtrepair of hernial defect gtRecurrence rate of 2.5 13.3 gtSubprosthetic Hernia gtWound healing complications due to direct contact of prosthesis with environment during wound revision OR cost P6000 available
Sublay prosthetic repair gtreduction of hernial contents gtrepair of hernial defect Recurrence rate of 1 - 20 OR cost P6000 available

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Clinical Questions

• 15. What home instructions can one give to
  patients who underwent incisional hernia repairs?
• Ans
• - Avoid straining
• Avoid lifting heavy objects/ learn the proper
  mechanics of lifting
• High fiber diet
• Quit smoking
• Maintain a healthy weight

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• THANK YOU

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References

• Nyhus. Hernia. Lippincott Co.1995
• Fitzgibobns, et al open hernia repair, Section 5
  Chapter 27 ACS Principles and Practice 2003