Abdominale wand pathologie

Abdominale wand pathologie 

Dr. Van den Bossche Bert 

Interuniversitair postgraduaat onderwijs 

17 april 2010 

© 2008 Universitair Ziekenhuis Gent 1

Definities 

Reduceerbare hernia: spontaan of door manuele druk 

terug te duwen in de buikholte 

Niet-reduceerbare of geincarcereerde hernia: inhoud kan 

niet teruggeduwd worden 

≠ obstructie 

≠ strangulatie 

© 2008 Universitair Ziekenhuis Gent 

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Indeling naar lokalisatie 

Hernia inguinalis 

Hernia umbilicalis 

Hernia epigastrica 

Hernia ventralis 

Hernia obturatorius 

Hernia sciatica 

Hernia perinealis 

Hernia dorsalis/lumbalis 

Spigeliaanse hernia 

Littré hernia 

Richter hernia 


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Liesbreukherstel : kunst of kwelling 


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Liesbreuken : hoe was het vroeger ? 


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Hernia inguinalis – Anatomie (1) 

Liesstreek (groin) 


Fascia transversalis 

Ligamentum inguinale (Poupart) 

Ligamentum pectineale (Cooper) 

Conjoint tendon (falx inguinalis) 

Fascia MOAE en MOAI 

Ruimte van Bogros 

Skandalakis JE et al. World J Surg 1989;13:490 

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Hernia inguinalis – Anatomie (2) 

N. Ilioinguinalis 

N.iliohypogastricus 

N. genitalis 


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Incidence of chronic pain: 14 to 15 % 


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Mechanism of nerve trauma 

Partial or complete transsection 

stretching 

contusion 

crushing 

cautery damage 

suture compression 


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Six manoevers to avoid nerve injury in 

open repair 

Avoiding indiscriminate division of the subcutaneus 

tissue 

avoiding removal of the cremaster muscle fibers 

avoiding extensive dissection of the iioinguinal nerve 

identifying and preserving all neural structures 

avoiding making the inguinal ring too tight 

avoiding placement of sutures in the lower edge of the 

internal oblique muscle 


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Neuropathic pain treatment 

Infiltration : local injection of 10 cc lidocain ( 1% ) 

Periostitis: Depo medrol 5 cc lidocaine and 40 mg 

methylprednisolone) 

Operative transsection: 

triple neurectomy + removal of mesh ( meshoma) 

high resection ! ( n 225 80 % resolution) 

Gabapentanoids / tricyclic drugs 

Acupuncture 

Pulsed radiofrequency techniques ( neurodestructive 

treatment) = highly controversial 


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Hernia inguinalis – Klinische diagnose 

Zwelling 

Pijn bij inspanning 

Uitstraling van pijn naar het scrotum 

Meestal beter in liggende houding 

Direct < indirect 

Klinisch onderzoek: vinger door externe ring met 

valsalva-maneuver 

Herniografie 


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Hernia inguinalis – Differentiaal diagnose 

Liespijn op basis van tendinitis of musculair 

Gynaecologische etiologie 

Lipoma van de funniculus 

Hydrocoele / varicocoele 

Lymfadenopathie 

Abcedaties 

Hematoom 


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Hernia inguinalis – Behandeling (1) 

Asymptomatische hernia? 

Rol van een breukband? 

Lokale anesthesie: bupivacaine 0.5% 

lidocaine 2% 

Infiltratie van de huid 

Zenuwblock mediaal van spina 

Infiltratie onder fascia MOAE 

Infiltratie tuberculum 

Infiltratie breukzak 


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Verschillende technieken 


Anterieur (open) 

Posterieur (open en laparoscopisch) 

Er bestaat geen “beste” techniek 

“Het beste is diegene die je het frekwentst doet” 

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Belangrijke algemene punten bij chirurgisch herstel: 

Onderkennen van mogelijke onderliggende etiologie 

Igv een indirecte breuk breukzak reseceren? 

Reconstructie van de bodem van het lieskanaal 

Bij een directe breuk altijd zoeken naar een breukzak! 

(13% dubbele hernia) 

Recidief (nieuw, therapeutisch falen, collageen) 


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Anterieure benadering: 

Bassini (zeer beperkte toepassing) 

Lichtenstein repair (USA) 

Shouldice (Canada) 

McVay-repair (preperitoneaal, veel tensie) 

Mesh-and plug repair 

Posterieure benadering: 

TAP 

TEP 

Kugel 

Polysoft 

PHS / UHS 


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Current guidelines (EHS 2008) 

• Lichtenstein tension free repair reported recurrence 

rates of 1-2%, although underestimated. 

• Easy to perform at relatively low cost. 

• Laparoscopic repair (TAP and TEP) reports low 

recurrence rates and very quick recovery to normal 

daily recovery. 


So, why look for other techniques ? 

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Primair liesbreukherstel 

Bassini – Mc Vay – shouldice 

Open en anterieur herstel 

Tension 

Postoperatieve pijn 

lange herstelperiode 

hoge recidiefkans 

Besmet milieu (darmnecrose) 


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Lichtenstein 

Referentie 

Anterieur herstel 

Tension free - prothese 

Recidieven 1 à 2 % 

Chronische pijn 

Niet voor femoraalbreuken 


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Richtlijnen voor Lichtenstein repair (1): 

Mesh 8x12cm 

2cm mediaal van tuberculum 

2-3cm naar craniaal 

Ligamentum inguinale 

4-5 lateraal van “nieuwe interne ring” 

Bescherming van de zenuwen 

Light weight mesh 

Resorbeerbare draad, afzonderlijke punten craniaal 


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General anterior view 


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Liesbreuken : types 


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Lichtenstein 

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Lichtenstein 

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Lichtenstein 

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Lichtenstein : chronische pijn 

Grondige dissectie 

Funiculus 


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Grondige dissectie 

Zenuwen 


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Grondige fixatie 

Mesh ligt op de inguinale 

zenuwen 

Reconstructie van een 

interne liesring 


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Anterieur - posterieur 


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Preperitoneaal herstel 

Prothese blijft ter plaatse door abdominale druk 

Geen contact met oppervlakkige zenuwen 

Grote overlap 


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laparoscopie 

TAPP 

Trans abdominal pre-peritoneal repair 

Toegang preperitoneaal via de abdominale caviteit met openen 

van peritoneum 

TEP 

Totally extra-peritoneal repair 

Preperitoneale ruimte wordt bekomen zonder peritoneum te 

openen. 


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laparoscopie 


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laparoscopie 


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Bedenkingen bij laparoscopie 

Algemene anaesthesie 

Lange learning curve – ervaring 


Meer recidieven ? 

Complicaties 

Hoge kostprijs 

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Preperitoneaal herstel via anterieure weg 

Kugel 

Ugahary 

POLYSOFT 

Rebound 


Moeilijke procedures 

Bijkomende opening in de abdominale wand 

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Polysoft / Kugel - techniek 

Anterieur 

Kleine incisie 

Minimale dissectie 

Via de herniatie 

Preperitoneaal 

Minimale fixatie 

dagkliniek 


Memory-ring 

Direct 

Femoral 

Notch for iliac vessels 

Ring interrupted 

Indirect 

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Polysoft /Kugel 

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Polysoft / Kugel 

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Polysoft / Kugel 

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TIPP : Indirect hernia 


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TIPP : self expandable memory ring patch 


Polysoft® Memory-ring 

Anatomical shape 

Notch for iliac vessels 

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Final position of the mesh: 


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Polysoft / Kugel: postoperatief 

Intrademaal gehecht 

Verband na 10 verwijderen 

Dagkliniek 

Maaltijd 

Mictie 

mobilisatie 

Week relatieve rust 

Pijnstilling ( NSAID – paracetamol) 


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Preperitoneal open approach vs Lichtenstein 

Nienhuijs S. et all Pain after open preperitoneal repair vs 

Lichtenstein : a randomized trial World J. Surg. 2007 

n= 172 

anterior approach = dissection of the inguinal canal = 

manipulation of the nerves 

Kugel mean VAS 0.3 vs 0.9 in Lichtenstein p = 0.002 at fu 

3 months 


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New developments in meshes 

polyester (dacron) 


ethylene glycol + terephthalic acid (1939) 

machine knitted (Mersilene) 

multifilament, macroporous (>75µ) 

degradable at longer time 

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© 2008 Universitair Ziekenhuis Gent 54


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Polypropylene (Marlex) 

Propane gas – Propylene – Polypropylene 

Fiber knitted (1963) 

Monofilament, macroporous (>75µ) 

Inflammatory response, shrinkage, BUT: 

Gold standard in mesh repair of abdominal wall hernia 


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Scar plate 

fold development with heavy weight PP mesh 

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ePTFE (teflon) 


expanded fully fluorinated polymer (1963) 

pores 20-25µ, microporous 

more prone to infection 

intra-abdominal use 

expensive 

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PVDF polyvinylidenfluoride 


non-absorbable 

macroporous polymer 

already routinely used 

more resistant to hydrolysis and degradation 

less inflammatory response 

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So enough possible mesh materials... 

But: 


how strong should it be? 16N/cm 

how strong is it? >5 times stronger 

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Development of larger pore sized, lighter weight meshes 

Two times stronger than physically possible 

Less foreign body reaction 

Less shrinkage 

Less scar plate 


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VYPRO II 

Multifilament ( Prolene / Vicryl ) 

50 % / 50 % 


ULTRAPRO 

Monofilament ( Prolene / Monocryl ) 

50 % / 50 % 

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Pore Size 

Ti MESH 35 gr 1 mm 

Ti MESH 16gr 1 mm 

BARD Mesh 1-2mm 

ATRIUM 1-2mm 

PROLENE 5mil 1-2mm 

PROLENE Soft 2-3mm 

VYPRO II 3-4mm 

VYPRO 4-5mm 

ULTRAPRO 3-4mm 


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Pore Size & Scar Tissue 


Inelastic, rigid tissue scar plate can form. 

The larger pore construction reduces connective tissue foreign body reaction by maximising 

areas not in contact with the foreign body. Also increases elasticity properties. 

A non-mesh structure, such as ePTFE becomes encapsulated rather 

than incorporated, and can migrate. 

foreign body scar tissue 

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Inelastic, rigid tissue scar plate can form. 

bridging + retraction = shrinkage ! 

foreign body 

scar tissue 

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PARIETENE : 129 g/ m² 

SURGIPRO : 127g/m² 

MARLEX : 95 g/m² 

ATRIUM : 92 g /m² 

PROLENE ( 5mils ) : 85 g/m² 

PROLENE SOFT : 45 g/m² 

TI MESH : 35 g/m²( Light ) 

16 g/m² ( Extralight ) 

VYPRO II : 75 g/m² ( 35g/m² ) 

VYPRO : 54 g/m² ( 26 g/m²) 

UlTRAPRO : 50 – 55 g/m² ( 28g/m²) 


LIGHTWEIGHT 

Non absorbable 

100% POLYPROPYLENE 

Composite meshes 

Partially absorbable 

LIGHTWEIGHT !! 

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Scar mesh , not a scar plate 

foldfree incorporation with lightweight Vypro II mesh 


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But still strong enough ? 

Pressure [mmHg] 

1800 

1600 

1400 

1200 

1000 

800 

maximal abdominal pressure 

600 

400 

200 

0 


Comparing abdominal pressures with mesh burst strength 

4 13 44 59 

150 

338 

Laying Standing Pain Pressing Coughing Vypro/PP Vypro II/PP Prolene Softpro Ultrapro/PP Mersilene 

375 

1650 

750 

525 

413 

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Clinical evidence? 

Inguinal hernia 


3 randomized controlled trials 

1 showed an increase in recurrence 

rate 

all showed less postoperative chronic pain 

Bringman 2006, O’Dwyer 2005, Post 2004 

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Incisional hernia 


1 randomized controlled trial 

showed an increase in recurrence 

rate (not significant) 

no difference in quality of life or pain 

perceptions 

Conze, 2005 

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Is this enough evidence to promote its use? 

Compare it with the evidence for using any type of mesh in 

incisional hernia repair: 


1 randomized trial comparing 

sutures and mesh repair!! 

Luijendijk, 2000; Burger, 2004. 

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And if you are not convinced... 

You can use mosquito nets! 


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Hernia femoralis 

4x meer bij vrouwen dan bij mannen 

Altijd controle bij repair van een liesbreuk 

33% van de breuken bij vrouwen, 2% bij de man 

Meer strangulatie 

Bulging aan de mediale zijde van de dij 

Onder het ligamentum inguinale 

DD met varix V saphena magna 

Repair: ver schillende mogelijkheden met sluiten van het 

femoraal kanaal 

Cave: tekenen van strangulatie 


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Hernia umbilicalis 

Meer bij vrouwen 

Risicofactoren: zwangerschap, ascites, obesiteit 

Kinderen: kan verdwijnen in de eerste levensjaren 

Volwassenen: chirurgisch herstel 

Repair: primair kan bij breukpoorten tot 1cm 

Groter dan 1cm: prothese 

Laparoscopisch of open 

Igv cirrhose: geen consensus over mesh of geen mesh 

Eerst controle over de ascites om genezing te bekomen 


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Hernia epigastrica 

Linea alba boven de navel 

3-5% van de populatie 

20% multipel! 

Symptomen vaak gerelateerd aan maaltijd 

DD rectus diastase, galsteenlijden, maagulcus 

Geen consensus over primair vs. Mesh 

10-20% recidief (meerdere breukpoorten) 


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Andere vormen 

Littre: Divertikel van meckel in de breukzak 

Spigeliaanse hernia: hernia thv linea semilunaris 

Lumbale hernia: Petit’s triangle and Grynfeltt’s triangle 

Obturator hernia: hoge mortaliteit (-40%) wegens 

miskenning en frekwentere incarceratie 

Perineale hernia: na rectumextirpatie of prostatectomie 

Sciatic hernia: grote en kleine foramen 


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Thank you 

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Incisionele hernia (1) 

Ongeveer 10% van alle laparotomieen 

Slechte sluitingstechniek 

Multiple ingrepen 

Wondinfecties 

Leeftijd 

Onderliggend lijden 

Obesiteit 

Pulmonale complicaties postoperatief 


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Herstel steeds middels mesh-placement 

Verschillende technieken: 


Rives-Stoppa (sublay), inlay, onlay etc. 

Component separation techniek 

Ramirez-incisies 

Laparoscopisch: geen verwijderen van de breukzak 

Gebruik van suturen aan te raden 

Cave: seroomvorming!! 

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Prognose: 

Small: 2-5% 

Medium: 5-15% 

Large: >25% 

Complicaties: huidnecrose, seromen, abdominaal 

compartiment syndroom…. 


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Definition 

Hernia after open or laparoscopic surgery, visible and 

palpable when patient is standing 

60 % of patients is asymptomatic 

Incarceration requires emergency surgery 


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Prevention and incidence 

10 – 15 % of laparotomy incisions 

Meta-analysis of Hodgson 

Abdominal fascial closure of midline laparotomy wounds with 

a continuous non-absorbable suture 32 % risk reduction in 

comparison with interrupted techniques 


Meta-analysis by Van „t Riet 

15 studies with 6566 patients 

Similar results 

LAPAROTOMY WOUNDS SHOULD BE CLOSED WITH 

A NON-ABSORBABLE OR VERY SLOW ABSORBABLE 

CONTINUOUS FASCIAL SUTURE 

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Controversies 

Absorbable >< non-absorbable sutures 


Non-absorbable 

= nidus for infection and sinus tract formation 

Continuous >< interrupted closure 

Continuous 

= quicker and spreads the tension 

Mass >< layered closure 

Meta-analysis by Weiland 12.247 patients 

Layered closure had higher hernia formation 

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Risk factors (1) 

Wound infection 

Abdominal distention 

Pulmonary complications 

Male gender 

Age 

Obesity 

Emergency procedures 


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Risk factors (2) 

Early reoperation 

Jaundice 

Underlying disease 

Type of closure 

Suture material 

Choice of original incision 


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Diagnosis 

Anamnesis 

Physical examination 

Ultrasound 

CT scan more efficient and accurate in defining the 

defect and for planning and choice of operation 


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Classification 

Localisation 

Size 

Recurrence 

Reducibility at the hernia gate 

Symptoms 


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Techniques of repair 

Primary repair 

Prosthetic mesh repair 


Onlay mesh repair 

Inlay mesh repair 

Retrorectus mesh repair 

Intraperitoneal underlay mesh repair 

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Primary repair 

For small defects < 5 cm 

Continuous or interrupted sutures to approximate the 

edges of the fascial defects (1 cm of the fascial edge 1 

cm advancement) = Mayo repair 

Recurrence rates > 50 % 

Always tension on the repair 


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Primary suture 


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Modifications of primary repair 

Bilateral relaxing incisions in the anterior rectus fascia 

for upper midline hernias 

Separation-of-parts technique = bilateral release of the 

external oblique muscle 


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Onlay mesh is sutured to the anterior rectus sheath, 

after primary closure of the fascial defect 

Advantage 


Mesh not in contact with abdominal content 

Disadvantages 

Repair under tension 

Large subcutaneous dissection > seroma formation > mesh 

infection 

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Onlay only (no primary closure of fascial defect) 

Advantage 


Less tension 

Cuff technique 

Sutures fixate the mesh around both anterior and posterior 

rectus sheath 

Disadvantages 

Extreme pain 

Necrosis viable rectus muscle and fascia 

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Inlay mesh repair 


Hernia sac is excised 

Recurrence rates 10 – 20 % 

Only when retrorectus or intraperitoneal mesh repair is not 

possible 

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Retrorectus mesh repair = Stoppa 


Hernia sac in place as a buffer 

Above umbilicus 

Dissection above posterior rectus fascia and underneath the rectus 

muscle 

Below the umbilicus 

No posterior rectus fascia, dissection in preperitoneal space 

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Retrorectus mesh repair = Stoppa 

Polypropylene mesh in space created and fixated to the muscle 

layer above with full or partial thickness sutures 


Recurrence rate < 10 % 

Mesh infection 5 - 12 % 

Pain > 10 %, usually resolves after complete ingrowth of the 

mesh 

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Open 


Opening hernia sac, adhesiolysis and fixation of the mesh 

intraperitoneal 

Laparoscopic 

Entering abdomen away from the defect, mesh fixed to the 

abdominal wall with partial thickness tacks or full thickness 

abdominal/fascial wall sutures 

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Laparoscopic 


Significant seroma rate 10 – 15 % 

Unrecognized bowel injuries 

Recurrence rate < 5 % 

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Ramirez and Component separation technique 


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Abdominale wand pathologie - Belsurg

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