Current management of incisional hernia

Endoscopy Conclave One Day Live Endoscopic Workshop & CME

01.09.2013Sunday, 8am-6pm

AC Auditorium-Level V@ Lotus hospital, Erode

Hosted byIMA TN SB- AMS Wing

IMA Erode BranchASI Erode City Chapter

Delegates: Rs:1000/- Postgraduates: Rs: 500/-

Morning Session: ( 8am-1`pm)•Live Endoscopy workshop: Basic

Diagnostic/ Banding of Varices/SclerotherapyDilatation of Stricture esophagus

•10 min Lectures on ‘Endoscopic Practice Guidelines ‘Endoscopic management of Corrosive stricture: When and How?:Management of variceal bleeding: Before and after endotherapy:Role of endoscopy in Upper GI malignancyFB esophagus:

•Live Endoscopy Workshop: AdvancedStent deployment/Glue Injection of Fundal varicesPolypectomy

•‘Futuristic’ Lectures: Tomorrow’s World of EndoscopyWhy surgeons should always be doing endoscopy?:Endoscopy in the era of Laparoscopy:

•Endo quiz:Post Lunch Session(2-4pm)•Panel Discussion: Team approach in the management of GI disorders:

GERD, Achalasia, Upper GIBleeding , Bile duct stones, •Live Colonoscopy/ERCP Workshop

Colonoscopic polypectomyBile duct stone removal/StentingPancreatic endotherapy

•Challenging situations for endoscopistUpper GI bleeding with normal endoscopy: How to proceed?:Difficulty reaching caecum during Ccolonoscopy : Tricks of the Trade:

Post Tea Session( 4-6pm)•Humour in Gastroenterology•Convocation and Award Ceremony at 4.30pm

CURRENT MANAGEMENT OF INCISIONAL HERNIA

Dr.S.EaswaramoorthyDr.TC.GnanasekaranDr.KV.Durairaj

ASI Erode City Branch

PROF.JR.SANKARAN SYMPOSIUM@ TN&P ASICON 2013

Symposium on Management of Incisional hernia. Dr.S.Easwaramoorthy 20min

Pathogenesis of Incisional hernia Prevention of incisional hernia Evaluation and Current management of incisional

hernia All, we should know about Mesh for hernia!

Dr.T.G.Gnanasekaran 15min Open mesh repair and abdominoplasty

Dr.K.V.Durai raj 15min Laparoscopic mesh repair of incisional hernia

Case scenarios and discussion 10min

Why it happens?...

Incisional HerniaWhy it happens?

Patient factorsSurgeon factors

Disease factors

Patient Factors

Obesity Diabetes Renal Failure Anaemia and

Hypoproteinemia Post Operative Chest

Infection

Disease Factors

Peritonitis Visceral Cancer/ascites Colostomy

Surgeon’s Factors

Incision Low midline/ Subcostal

Drain/Stoma Wound Protection Suturing Technique

Suturing Technique

Type of Suture material Absorbable :

Vicryl/PDS/Dexon Non absorbable :

Nylon/Prolene/Ethibond

Size of Suture Technique of Suturing

Peritoneum?1 cm across and 1 cm apartRule of 4

Clinical Assessment

Lying Standing

Loss of Abdominal Domain

Role of Imaging in Incisional Hernia

CT Abdomen

How to manage Incisional hernia?

Open procedure (with Abdominoplasty) Anatomical Repair Component Separation technique Mesh repair

Sublay, Inlay, Onlay

Laparoscopic repair IPOM

How to manage Incisional hernia?

Open procedure (with Abdominoplasty) Anatomical Repair Component Separation technique Mesh repair

Laparoscopic repair Mesh repair

Mesh is a must…

Why Mesh?

Low recurrence rate Inguinal hernia repair

Bassini’s repair : 10% Shouldice repair : 1% Lichtenstein’s Mesh repair : <1%

Ventral hernia Suture Vs Mesh: : 50% Vs 10%

Tension free & Pain free Quick recovery Quick to learn and easy to do!

Why Mesh?Pathogenesis of Hernia Defective Collagen

Reduced ratio of type I and type III collagen Type I: Mature Collagen, strong and normal tissue Type III: Immature Collagen, weak, in healing wounds Type I : Type III ratio normally is 4:1

Connective tissue pathology is not only a cause of primary herniation but its presence can prevent cure!

Increased matrix metalloproteinase activity(MMP)

‘Understand the Wound Biology’

A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia?Raphael Rosch, Uwe Klinge, Zhongyi Si, Karsten Junge, Bernd Klosterhalfen, and Volker Schumpelick, BMC Med Genet. 2002; 3: 2.

Lichtenstein’s Mesh Repair

Tension Free repair• Under LA• Day care• Low recurrence rate!

Billroth’s Vision

‘‘If we could artificially produce tissues of the density and toughness of fascia and tendon the secret of the radical cure of hernia wouldbe discovered’’.

- Beitrage zur Chirurgie (1878)

Inventor of Prosthetic Mesh repair: Dr. Francis Usher (1908-1980)

• Inventor of Polyehylene(Marlex) and Polypropylene mesh• Several Animal studies about their inertness• 20 papers• Innovative ways of placing the meshes: Inlay, Overlay, Sandwich tech etc

Stoppa’s Mesh Repair

Pre peritoneal Mesh Over Myopectineal Orifice

GPRVS

‘‘In the adult, repairinginguinal hernias in the inguinal canal and femoral herniasin the femoral canal is like closing the curtain insteadof shutting the window’’

Mesh repair of Incisional Hernia

Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

Types of Mesh Synthetic Mesh

Non absorbable Polyprophylene(Prolene) Polyethylene(Marlex) Polyester(Dacron) PTFE (Teflon/Gordex)

Absorbable Vicryl

Combined Vipro

Synthetic with Absorbable Barrier( Dual mesh) Parietex Proceed Etc

Biological Mesh Surgisis ( Porcine submucosa) Alloderm (Cadaveric human dermis)

What MeshLight weight Vs Heavy weight?

Light weight Mesh Heavy weight Mesh

Definition?

Light wt, thin fibres, macro pores (>1.5mm)Less amt of FB

Heavy wt, thick fibres, micro pores (< 1.5mm)So more amount of FB

Qualities FlexibleLess FB reaction and pain

StifferMore FB reaction and pain(Problem of adhesion, fistula)Shrinks moreStronger! - so what

Examples Ultrapro, Vipro Marlex, Dacron, PTEF

The lightweight and large porous mesh concept for hernia repair.Klosterhalfen B, Junge K, Klinge U. Expert Rev Med Devices. 2005 Jan;2(1):103-17.

Laparoscopic Ventral Hernia RepairChoice of Composite Mesh

Name Parietal side Visceral Side Longevity

Remarks By

Parietex Polyester Atelocollagen, PEG, Glycerol

20 days

expensive Covidien

Proceed Polypropylene

Oxidised (ORC) regenerated cellulose/PDS

30 days

Ethicon

Sepramesh

PP PGA/Hydrogel

30 days

Davol

C QUR PP Omega 3 FA Atrium

Pro VISC 160

Polyester Polyurethane Life Cost effective

Lotus

Dual Mesh e PTFE (rough)

e PTFE(smooth)

Life Gore

Kugel/Composix

PP(HW) e PTFE Life Cann’t trim Bard

Parietex Mesh

Features:

Polyester with Collagen cover on the visceral side

No adhesion or infection

Handles well during Lap

Holds sutures well Can be trimmed

Moreno-Egea A, Liron R Girela E, Aguayo JL. Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience. 2001 Surg Laparoc Endosc Percutan Tech Apr;11(2):103-6

Proceed Mesh (Ethicon) Parietal Side

PP(LW) encapsulaed in PDS Blue stripped side

Visceral Side ORC ( Oxidised regenerated

cellulose)

Macroporous Conforms to anatomy Can be trimmed

Downside: Ensure meticulous

hemostasis

or else adhesions likely Shrinks by 30% Delamination and seroma

Proceed Mesh (Ethicon)Time line

1 week

2 weeks

Day 1

3 months

Pro VISC 160

Polyester White Parietal side

Polyurethane Blue smooth visceral

side

With Sutures Pre cut in various

sizes

Parietal side: PPVisceral side: e PTFE

Bard (Composix) Gore Dual Mesh

Parietal side: Rough PTFEVisceral side: smooth PTFE

Mesh repair of Incisional Hernia

Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

Where to place the Mesh?On Lay In Lay

Under Lay IPOM

Pascal’s Hydrostatic Principle

Onlay Vs Inlay

Effect of Intra abdominal Pressure

Choose a mesh at least 5cm larger than the defect all

round.

Mesh repair of Incisional Hernia

Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

Mesh Fixation Methods…

AbsorbaTack (Covidien)

Permasorb (Davol / Bard )

Fibrin sealant

Spiral Tackers

Staples

Fibrin Glue

Suture

Trans Facial Suture Fixation

Ideal Fixation Method

No Type of Fixation

Features

1 Trans Fascial suture fixation

Chronic pain

2 Suturing 2cm apart

3 Spiral Titatinum Tackers

2cm apartDouble crown techniqueNerve entrapment, adhesion, rarely tacker hernia

4 Absorbable tackers

For initial 1 year

5 Fibrin Glue Suitable for inguinal hernia? Ventral Hernia: Alternative or Adjunct: needs trial.

Closure of Hernia defect to avoid mesh protrusion or displacement

To with stand the intra abdominal tangential force and also shearing Force due to abdominal muscle contraction

Mesh repair of Incisional Hernia

Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

Mesh Related Complications…

Infection Surgeon’s nightmare

Intestinal adhesions Composite mesh for laparoscopic ventral hernia repair

Bowel obstructions

Erosion of the prosthesis into the adjacent hollow viscus

Contraction of prosthesis At least 5cm larger than the size of the defect

Prevention of Mesh infectionConsider

Patient factors Smoking DM Obesity Re operation Big incision

Type of Mesh Macroporous vs microporous Impregnated mesh

Technique Lap Vs Open On lay Vs In lay

Prophylactic antibiotics Avoid unplanned

enterotomy Infected field

Absorbable mesh Biological mesh

Ventral hernia repair•Risk of infection is 3-10% in Open mesh repair•Risk of infection is < 1% in Lap Mesh repair

Conclusion

Mesh repair of abdominal wall hernia is the Standard of Care.

Composite mesh has to be used for ventral hernia

Avoid Mesh related complications , if possible

Next

Dr.T.G.Gnanasekaran 15min Open mesh repair and abdominoplasty

Dr.K.V.Durai raj 15min Laparoscopic mesh repair of incisional

hernia Case scenarios and discussion

10min

•21year old lady,•Para 1•Large Incisional hernia following

c-section•Yet to complete her family

•Surgery Vs Conservative treatment•Pregnancy after a mesh repair•Mesh repair during C-section

Case 1

•40 year old obese lady•Abdominal hysterectomy 5 years ago•Incisional Hernia in Lower midline scar•Has Symptomatic Gall stones

•Open /Laparoscopic/Combined

Case 2

•35 year old lady•Laparoscopic hysterectomy 6 months ago•Umbilical Port site Hernia

•Why?•Suture Vs Mesh?

Case 3

Endoscopy Conclave One Day Live Endoscopic Workshop & CME

01.09.2013Sunday, 8am-6pm

AC Auditorium-Level V@ Lotus hospital, Erode

Hosted byIMA TN SB- AMS Wing

IMA Erode BranchASI Erode City Chapter

Delegates: Rs:1000/- Postgraduates: Rs: 500/-