Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (21 page)
Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Much of what has been mentioned above is applicable to hernia repair in the emergency situation. However, there are a few dilemmas that occur more frequently in the emergency setting. Patients who present as an emergency but have no bowel compromise can be treated as per elective hernia surgery. When bowel is compromised, especially when there has been significant contamination, current opinion is that synthetic mesh should not be used. However, there is little in the way of evidence apart from anecdote to support such a view and this view has been challenged.
64
The case for biological mesh in such scenarios is also lacking in evidence.
65
For those who support the laparoscopic approach, it is not unreasonable to offer this in the emergency setting and laparoscope the patient with an irreducible inguinal hernia. If the bowel can be reduced and is viable, then convert the operation to a TEP and place mesh as usual. If the bowel is compromised, then resect the bowel through a small incision and return 6 weeks later for a TEP. In the emergency incisional/ventral hernia setting, if the hernia is large, then proceed directly to open sublay mesh repair. If the hernia is smaller, then laparoscopy and intra-abdominal mesh are appropriate if there is no bowel compromise. If there is bowel ischaemia, then convert to the open sublay repair. The use of mesh in the sublay space in the emergency setting should not be associated with an increase in mesh infection as it lies external to the peritoneal cavity, but clearly each case will need to be assessed individually.
Emergency hernia surgery remains a high-risk surgical procedure, with the main risk factor for postoperative mortality being infarcted bowel.
66,
67
Such operations should not be left to junior members of the surgical and anaesthetic teams. Appropriate resuscitation, followed by timely and appropriate surgery, may save lives. Occasionally, the techniques of damage limitation surgery (see
Chapter 13
) may be appropriate.
This is a hernia with an increasing incidence associated with the increase in laparoscopic surgery. Insertion of larger ports through the midline as opposed to more laterally appears to be a significant risk factor. This is especially true in the presence of a divarification of the recti or an unrecognised umbilical hernia. There is little evidence to support closure of the fascia except when a cut-down is performed for the first port. The use of dilating rather than cutting trocar tips may reduce the incidence of port-site hernia formation.
In general, elective hernia surgery to the groin and ventral regions does not require antibiotic prophylaxis.
68,
69
However, as the risk of bowel injury is always present in incisional hernia surgery, it would be reasonable to give routine antibiotic prophylaxis for such surgery. Patients at increased risk of infection, including the immunocompromised, skin conditions with higher bacterial carriage such as psoriasis and in the emergency setting, all merit antibiotic prophylaxis.
All theatres have bacteria (called colony-forming units) in the circulating theatre air. It therefore makes sense to open the mesh just before it is required during the operation. Changing to fresh gloves before the handling of the mesh, minimising mesh contact with the skin and inserting the mesh deep to the subcutaneous tissues may all help reduce the risk of mesh contamination. The author uses a gentamicin solution (240 mg gentamicin in 250 mL normal saline) to irrigate larger meshes following insertion, although there is no evidence-based medicine to support this manoeuvre. Methicillin-resistant
Staphylococcus aureus
(MRSA) bacteria have been found on mesh several years after insertion, so prophylaxis to MRSA is appropriate if a previous repair has been complicated by MRSA infection.
The topic of prophylactic mesh insertion to minimise subsequent hernia formation in high-risk groups of patients remains controversial. One study reduced the incidence of incisional hernia following open gastric bypass surgery from 21% to 0% by the prophylactic insertion of a polypropylene mesh in the sublay position.
70
Another study reduced the incidence of parastomal hernia following permanent end colostomy from 50% to 5% by the prophylactic insertion of a polypropylene mesh in the sublay position at 2 years' follow-up.
71
At 5 years' the rates were 81% and 13%, respectively.
72
Both studies have small patient numbers, but no increase in morbidity was noted in the prophylactic mesh group. It is likely that prophylactic mesh to minimise subsequent hernia formation will become more mainstream practice. This may be supported by preoperative collagen type I/III ratio typing to perhaps select patients more at risk. This concept of collagen disease is important, and introduces the notion that hernia repair of any type will fail if the patient lives long enough. It is true that some surgeons' repairs last longer than others, so technical factors remain important, and mesh repairs at any time point are more likely to be intact compared to a suture repair.
56
(Re-operation rates are a surrogate for recurrence rates, although re-operation will underestimate the true recurrence rate.) However, a hernia repair at present is a patch-up job, and will probably fail eventually (if the patient lives long enough). Nevertheless, randomised trials in patients at high risk of developing incisional hernia are ongoing.
In general, an infected mesh has to be removed or exposed to the surface. If the mesh is lying in a pool of pus with no adherence to the patient, then the only option is removal of the mesh. If the mesh is partly embedded in tissue, then if there is adequate drainage through an open wound, many infected meshes will slowly granulate over and remain sound. However, sometimes chronic sinuses will develop and the only option is excision of these along with as much of the visible mesh as possible. Not all patients who require mesh removal will develop a hernia recurrence, although the majority probably will at some stage in the future.
73
It is the author's opinion that it is best to remove as much of the mesh foreign body as possible, control the sepsis and return at a later date for further repair. The use of biological mesh in a contaminated field is rarely indicated. The use of vacuum-assisted dressing to control the fluid exudates from the wound may aid wound care in such patients.
Key points
Herniorrhaphy is one of the commonest operations performed.
Techniques advanced considerably during the 1990s.
The use of prosthetic mesh should now be considered for the repair of all hernias.
The laparoscopic approach may be more appropriate than a traditional open approach.
Recurrent hernias may be best managed in specialist centres or by surgeons with a specialist interest in hernia surgery who are technically competent to perform both open and laparoscopic procedures.
A multidisciplinary approach, including plastic surgeons, may be appropriate for complex, multiply recurrent hernias.
1.
Wagh, P.V., Leverich, A.P., Sun, C.N., et al, Direct inguinal herniation in men: a disease of collagen.
J Surg Res
1974;17:425–433.
4437165
2.
Si, Z., Rhanjit, B., Rosch, R., et al, Impaired balance of type I and type III procollagen mRNA in cultured fibroblasts of patients with incisional hernia.
Surgery
2002;131:324–331.
11894038
3.
Junge, K., Klinge, U., Rosch, R., et al, Decreased collagen typeI/III in patients with recurring hernia after implantation of alloplastic prostheses.
Langenbecks Arch Surg
2004;389:17–22.
14576942
4.
Junge, K., Klinge, U., Prescher, A., et al, Elasticity of the anterior abdominal wall and impact for reparation of incisional hernias using mesh implants.
Hernia
2001;5:113–118.
11759794
5.
Klinge, U., Klosterhalfen, B. Modified classification of surgical meshes for hernia repair based on the analyses of 1,000 explanted meshes.
Hernia
. 2012;16:251–258.
6.
Cobb, W.S., Kercher, K.W., Heniford, B.T., The argument for lightweight polypropylene mesh in hernia repair.
Surg Innov
2005;12:63–69.
15846448
7.
Akolekar, D., Kumar, S., Khan, L.R., et al. Comparison of recurrence with lightweight composite polypropylene mesh and heavyweight mesh in laparoscopic totally extraperitoneal inguinal hernia repair: an audit of 1232 repairs.
Hernia
. 2008;12:39–43.
8.
Holm, J.A., de Wall, L.C., Steyerberg, E.W., et al, Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery.
World J Surg
2007;31:423–429.
17180562
9.
LeBlanc, K.A., Booth, W.V., Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings.
Surg Laparosc Endosc
1993;3:39–41.
8258069
10.
Askar, O.M., Aponeurotic hernias: recent observations upon paraumbilical and epigastric hernias.
Surg Clin North Am
1984;64:315–329.
6233735
11.
Sibley, W.L., III., Lynn, H.B., Harris, L.E., A 25-year study of infantile umbilical hernias.
Surgery
1964;55:462–470.
14133107
12.
Mayo, W.J., An operation for the radical cure of umbilical hernia.
Ann Surg
1901;34:276–278.
17861015
13.
Rowe, M.I., Clatworthy, H.W., Jr., Incarcerated and strangulated hernias in children.
Arch Surg
1970;101:136–143.
5451192
14.
Schier, F., Laparoscopic inguinal hernia repair – a prospective personal series of 542 children.
J Pediatr Surg
2006;41:1081–1084.
16769338
15.
Kurlan, M.Z., Web, P.B., Piedad, O.H., Inguinal herniorrhaphy by the Mitchell Banks technique.
J Pediatr Surg
1972;7:427–431.
5049854
16.
Hughson, W. The persistence or performed sac in relation to oblique inguinal hernia.
Surg Gynecol Obstet
. 1925;41:610–614.
17.
Lichtenstein, I.L., Shulman, A.G., Amid, P.K., et al, The tension-free hernioplasty.
Am J Surg
1989;157:188–193.
2916733
18.
Ger, R., The management of certain abdominal hernias by intra-abdominal closure of the neck.
Ann R Coll Surg Engl
1982;64:342–345.
7114772
19.
Ger, R., Monroe, K., Duvivier, R., et al, Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac.
Am J Surg
1990;159:370–376.
2138432
20.
Gazayerli, M.M., Anatomical laparoscopic hernia repair of direct or indirect inguinal hernias using the transversalis fascia and iliopubic tract.
Surg Laparosc Endosc
1992;2:49–52.
1341500
21.
Nyhus, L.M., Pollak, R., Bombeck, C.T., et al. The preperitoneal approach and prosthetic buttress repair for recurrent hernia.
Ann Surg
. 1988;203:733–738.
22.
Toy, F.K., Smoot, R.T., Jr. Laparoscopic herniorrhaphy update.
Laparoendosc Surg
. 1992;2:197–199.
23.
Annandale, T. Case in which a reducible oblique and direct inguinal and femoral hernia existed on the same side and were successfully treated by operation.
Edinb Med J
. 1876;27:1087–1089.
24.
Taylor, C., Layani, L., Liew, V., et al, Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomized clinical trial.
Surg Endosc
2008;22:757–763.
17885789
25.
National Institute for Clinical Excellence Laparoscopic surgery for inguinal hernia repair. Technology Appraisal Guidance 83. London: NICE; 2004. Available at.
www.nice.org.uk/TA083guidance
[[accessed 02.08.12]].
An excellent meta-analysis of open versus laparoscopic inguinal hernia repair.
26.
van Veen, R.N., Wijsmuller, A.R., Vrijland, W.W., et al, Long term follow up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia.
Br J Surg
2007;94:506–510.
17279491
27.
Fitzgibbons, R.J., Can we be sure polypropylene mesh causes infertility.
Ann Surg
2005;241:559–561.
15798456
28.
Franneby, U., Sandblom, G., Nordin, P., et al, Risk factors for long-term pain after hernia surgery.
Ann Surg
2006;244:212–219.
16858183
29.
Aasvang, E.K., Gmaehle, E., Hansen, J.B., et al. Predictive risk factors for persistent postherniotomy pain.
Anaesthesiology
. 2010;112:957–969.
Chronic pain can be predicted prior to surgery with simple bedside tests.
30.
Shouldice, E.B., The Shouldice repair for groin hernias.
Surg Clin North Am
2003;83:1163–1187.
14533909
31.
Shulman, A.G., Amid, P.K., Lichtenstein, I.L., The safety of mesh repair for primary inguinal hernias.
Am Surg
1992;58:255–259.
1586085
32.
McCormack, K., Wake, B., Perez, J., et al. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation.
Health Technol Assess
. 2005;9:1–203.
Cost analysis of laparoscopic compared to open surgery using the same data that were used for the 2004 NICE report (Ref. 25 above).
33.
Duff, M., Mofidi, R., Nixon, S.J. Routine laparoscopic repair of primary unilateral inguinal hernias – a viable alternative in the day surgery unit?
Surgeon
. 2007;5:209–212.
34.
Eklund, A., Rudberg, C., Smedberg, S., et al, Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair.
Br J Surg
2006;93:1060–1068.
16862612
35.
Atkinson, H.D.E., Nicol, S.G., Purkayastha, S., et al. Surgical management of inguinal hernia: retrospective cohort study in southeastern Scotland 1985–2001.
Br Med J
. 2004;329:1315–1316.
36.
Herzog, U., Das Leistenhernienrezidiv.
Schweiz Rundsch Med Prax
1990;79:1166–1169.
2237039
37.
Wantz, G.E., The Canadian repair: personal observations.
World J Surg
1989;13:516–521.
2815796
38.
Shulman, A.G., Amid, P.K., Lichtenstein, I.L., The plug repair of 1402 recurrent inguinal hernias: 20-year experience.
Arch Surg
1990;125:265–267.
2302067
39.
Bendavid, R., The rational use of mesh in hernias: a perspective.
Int Surg
1992;77:229–231.
1478799
40.
Fong, Y., Wantz, G.E., Prevention of ischaemicorchitis during inguinal hernioplasty.
Surg Gynecol Obstet
1992;174:399–402.
1570618
41.
Schaap, H.M., van de Pavoordt, H., Bast, T.J., The preperitoneal approach in the repair of recurrent inguinal hernias.
Surg Gynecol Obstet
1992;174:460–464.
1595021
42.
Beets, G.L., Dirkoen, C.D., Go, P.M., et al, Open or laparoscopic mesh repair for recurrent inguinal hernia. A randomised controlled trial.
Surg Endosc
1999;13:323–327.
10094739
43.
Langer, I., Herjog, U., Schuppisser, J.P., et al, Preperitoneal prosthesis implantation in surgical management of recurrent inguinal hernia. Retrospective evaluation of our results 1989–1994.
Chirurg
1996;67:394–402.
8646927
44.
Sevonius, D., Gunnarsson, U., Nordin, P., et al, Recurrent groin hernia surgery.
Br J Surg
2011;98:1489–1494.
21618495
45.
O'Dwyer, P.J., Norrie, J., Alani, A., et al. Observation or operation for patients with an asymptomatic inguinal hernia. A randomized clinical trial.
Ann Surg
. 2006;244:167–173.
The first randomised trial on surgery versus no surgery in the asymptomatic hernia.
46.
Fitzgibbons, R.J., Giobbie-Hurder, A., Gibbs, J.O., et al, Watchful waiting vs repair of inguinal hernia in minimally symptomatic men. A randomized clinical trial.
JAMA
2007;295:285–292.
13129988
47.
Yalamarthi, S., Kumar, S., Stapleton, E., et al, Laparoscopic totally extraperitoneal mesh repair for femoral hernia.
J Laparoendosc Adv Surg Tech A
2004;14:358–361.
15684782
48.
Hermandez-Richter, T., Schardey, H.M., Rau, H.G., et al, The femoral hernia. An ideal approach for the transabdominal preperitoneal technique (TAPP).
Surg Endosc
2000;14:736–740.
10954820
49.
Ceydeli, A., Rucinski, J., Wise, L., Finding the best abdominal closure: an evidence-based review of the literature.
Curr Surg
2005;62:220–225.
15796944
50.
Bloemen, A., van Dooren, P., Huizinga, B.F., et al, Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure.
Br J Surg
2011;98:633–639.
21254041
51.
Seiler, C.M., Bruckner, T., Diener, M.K., et al, Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisionals: a multicentre randomized trial (INSECT).
Ann Surg
2011;249:576–582.
19300233
52.
Millbourn, D., Cengiz, Y., Israelsson, L.A., Effect of stitch length on wound complications after closure of midline incisions. A randomized controlled trial.
Arch Surg
2009;144:1056–1059.
19917943
53.
Millbourn, D., Cengiz, Y., Israelsson, L.A., Risk factors for wound complications in midline abdominal incisions related to the size of the stitches.
Hernia
2011;15:261–266.
21279664
54.
Luijendijk, R.W., Hop, W.C., van den Tol, M.P., et al. A comparison of suture repair with mesh repair for incisional hernia.
N Engl J Med
. 2000;343:392–398.
The first randomised trial to demonstrate the benefit of mesh in reducing recurrence in incisional hernia repair.
55.
Burger, J.W., Luijendijk, R.W., Hop, W.C., et al, Long term follow up of a randomized controlled trial of suture versus mesh repair of incisional hernia.
Ann Surg
2004;240:578–583.
15383785
56.
Flum, D.R., Horvath, K., Koepsell, T., Have outcomes of incisional hernia repair improved with time.
Ann Surg
2003;237:129–135.
12496540
57.
Kingsnorth, A.N., Shahid, M.K., Valliattu, A.J., et al. Open onlay mesh repair for major abdominal wall hernias with selective use of component separation and fibrin sealant.
World J Surg
. 2008;32:26–30.
58.
Langer, C., Liersch, T., Kley, C., et al, Twenty five years of experience in incisional hernia surgery. A comparative retrospective study of 432 incisional hernia repairs.
Chirurg
2003;74:638–645.
12883791
59.
de Vries Reilingh, T.S., van Geldere, D., Langenhorst, B.L.A.M., et al. Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques.
Hernia
. 2004;8:56–59.
60.
Kaafarani, H.M., Hur, K., Campasano, M., et al, Classification and valuation of post-operative complications in a randomized trial of open versus laparoscopic ventral herniorrhaphy.
Hernia
2010;14:231–235.
20213456
61.
Motson, R.W., Engledow, A.H., Medhurst, C., et al, Laparoscopic incisional hernia repair with a self-centring suture.
Br J Surg
2006;93:1549–1553.
17048281
62.
Tse, G.H., Stutchfield, B.M., Duckworth, A.D., et al, Pseudo-recurrence following laparoscopic ventral and incisional hernia repair.
Hernia
2010;14:583–588.
20658350
63.
LeBlanc, K.A., Elieson, M.J., Corder, J.M., Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: a review of the literature.
JSLS
2007;11:408–414.
18237502
64.
Kelly, M.E., Behrman, S.W., The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds.
Am Surg
2002;68:524–529.
12079133
65.
Ventral Hernia Working Group, Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of the repair.
Surgery
2010;148:544–558.
20304452
66.
Nilsson, H., Stylianidis, G., Haapamaki, M., et al, Mortality after groin hernia surgery.
Ann Surg
2007;245:656–660.
17414617
67.
Derici, H., Unalp, H.R., Bozdaq, A.D., Factors affecting morbidity and mortality in incarcerated abdominal wall hernia.
Hernia
2007;11:341–346.
17440794
68.
Sanchez-Manuel, F.J., Lozano-Garcia, J., Seco-Gil, J.L. Antibiotic prophylaxis for hernia repair.
Cochrane Database Syst Rev
. 2007. [CD003769].
The latest meta-analysis on this topic.
69.
SIGN. Antibiotic prophylaxis in surgery. Guideline 104, 2008.
www.sign.ac.uk
[[accessed 02.08.12]].
The SIGN website allows all guidelines produced to date to be downloaded for free. An excellent reference source on current best practice in a variety of medical and surgical conditions.