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Case Presentation and Discussion on Strangulated Incisional Hernia

Marlou O. Padua, MD


General Data: T.R., 45 years old, female


Chief Complaint:  Abdominal pain

History Of Present Illness:

8 yrs PTA                underwent Caesarian Section at Metropolitan Hospital

                             on and off mass at RLQ of abdomen

                             (+) occasional pain

                             progressive enlargement of mass becoming irreducible

 1 day PTA              (+) abdominal pain , RLQ area, dull, aching, non-radiating

                             (+) nausea, (+) vomiting, (-) BM, (+) flatus  

                             consulted at a local health center

given HNBB, with no relief

 Persistence             Consult                               

Past Medical History:

    1975 – Appendectomy – OMMC

     (-) HPN                            (-) asthma

     (-) Heart disease               (-) DM

Review of Systems:

(-) weight loss

(-) fever

(-) melena

(-) dysuria

(-) tea-colored urine

Physical Examination:

Gen. Survey:  conscious, coherent, ambulatory

Vital Signs: BP – 110/70     PR – 96         RR – 20         T – 37.8oC

HEENT: pink palpebral conjunctiva, anicteric sclerae, no cervical lymphadenopathies

Chest/Lungs:  symmetrical chest expansion, equal & clear breath sounds

CVS:  adynamic precordium, normal rate, regular rhythm

Abdomen:

 

(+) 15 x 15 cm mass, RLQ, soft,

tender, non-reducible, (-) bowel sounds

 

(+) 2 cm indented scar at the

middle of the mass,

from previous drain site

 

R paramedian scar

 

CS (Pfannensteil) scar

 

Rectal Exam:  no skin tags, good sphincter tone, empty, collapsed rectal vault, no mass,  no feces on examining finger

  

Salient Features:

•  RLQ mass x 8 years, progressively enlarging and becoming irreducible

•  (+) history of previous operations

•  (+) abdominal pain

•  (-) BM x 1 day

•  (+) nausea/vomiting

•  Collapsed rectal vault

 

Clinical Diagnosis:

Diagnosis Certainty Treatment
Incisional Hernia, Strangulated 80% Surgical
Incisional Hernia, Incarcerated 20% Surgical

 

Algorithm:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paraclinical Diagnostic Procedure:

Do I need a paraclinical diagnostic procedure?

Yes, to confirm presence of small bowel obstruction

 

Paraclinical Diagnostic Options:

  Benefit Risk

Cost

Availability
Plain Abdominal X-Ray

show air fluid levels

exposure to radiation

Php 150 ✔✔

Ultrasound

can assess peristalsis

differentiate mechanical obstruction from ileus

nil Php 300 ✔✔

CT Scan

 

useful in obese patients

will show vascular compromise

exposure to radiation

Php 5,000

 

Plain Abdominal X-Ray:

•  Homogenous mass density noted at RLQ at the level of ASIS

•  Shows focal small bowel dilatation in the lower abdominal region – beginning obstruction

 

Pre-Treatment  Diagnosis:

Diagnosis Certainty
Incisional Hernia, Strangulated 90%
Incisional Hernia, Incarcerated 10%

 

Algorithm:

 

 

 

 

 

 

 

Goals of Treatment:

•  To close the fascial defect

•  To resect strangulated bowel

 

Treatment Options:

  Benefit Risk

Cost

Availability

Primary Repair

 

close the fascial defect

 

primary repair, recurrence  rate range from 24-54%

infection

bleeding

Php 5,000

✔✔

Open with Mesh

tension free closure of fascial defect

primary repair, recurrence  rate range up to 34%

infection

bleeding

Php 8,000

✔✔

Laparascopic

 

tension free repair

less tissue dissection &disruption of tissue planes

less pain postop

low intra-operative and postoperative   complications

early return to work.

infection

bleeding

Php 20,000

 

Pre-operative Preparation:

•   Informed consent secured

•   Psychosocial support provided

•   Optimized patient’s physical health

-  Fluid resuscitation

-  Nasogastric decompression

-  Prophylactic antibiotics

•   Patient screened for any health condition

•   Operative materials secured

 

Intra-operative Management:

Incision: Right paramedian over previous incision

Exposure:  long enough to facilitate accurate intra-operative evaluation, in an area that will facilitate the treatment goal.

 

Intra-operative Findings:

•   500 cc straw colored peritoneal fluid

•   (+) adhesions of omentum to peritoneum

•   (+) incarcerated part of omentum and part of ileum

•   15 cm of gangrenous (antimesenteric border) ileum, 50 cms from  Ligament of Treitz, strangulated into a  2 cm  defect at the RLQ from previous drain site.

•   Proximal segment of small bowel distended and edematous.

 

Intra-operative Diagnosis:

Strangulated Incisional Hernia

 

Algorithm:

 

 

 

 

 

 

 

 

 

 

Intra-operative Goals of Treatment:

•   Resection anastomosis of gangrenous ileum

•   Irrigate the abdomen

•   Leave subcutaneous tissue open to prevent surgical site infection

 

Intra-operative Treatment Options:

  Benefit Risk

Cost

Availability

Resection with Primary Anastomosis

prevent fluid and electrolyte losses from ileostomy

anastomotic leak

Php 5,000

✔✔

Double Barrel Ileostomy

  fluid and electrolyte losses Php 5,000

✔✔

 

Intra-operative Management:

•   Peritoneal fluid suctioned

•   Adhesiolysis

•   Omentectomy

•   Another incision over previous drain site

•   Gangrenous ileum reduced

•   Resection anastomosis, ileum

•   Hernial sac dissected from subcutaneous tissue

•   Peritoneal lavage

•   Primary repair of incisional hernia

•   Hemostasis

•   Complete sponge, needle & instrument count

•   Posterior and anterior rectus sheath closed

•   Subcutaneous tissue and skin left open

 

Operation Done:

Exploratory Laparotomy, Resection Anastomosis, Ileum; Repair of Incisional Hernia

 

Post-operative Care:

•   Supply the basic needs of the patient

    -  Comfort

    -  Antibiotics

    -  Analgesics

    -  Fluids and electrolytes

    -  Nutrition

•   Support organ function

•   Wound care

•   Advice on

    -  Wound care - daily flushing with Daikin’s solution

    -  Continue oral antibiotics


Follow-Up Plan:

•  Wound cleaning

•  Advice on possible recurrence

 

Outcome:

•   Resolution of the bowel obstruction 2’ to strangulated incisional hernia

•   Live patient

•   No complications

•   Satisfied patient

•   No medico-legal suit

 

Discussion:

Incisional Hernia

The iatrogenic incisional hernia develops as a late complication of about 10% of abdominal surgery. The hernia may be apparent within the first year post-operatively, but may not develop for up to 5 years. Despite awareness of the predisposing factors, the incidence is not decreasing.

Usually, the incisional hernia presents as a bulge in the abdominal wall near a previous wound. The condition is often asymptomatic but occasionally, a narrow-necked hernia occurs and presents with pain or strangulation. Once developed, it tends to enlarge progressively and may become a nuisance cosmetically or for dressing.

Treatment is by repair. Small hernia's recur in 2-5% of cases; medium sized hernias recur in 5-15%; and large hernias recur in 5-15%.

Incisional hernias can present in a variety of different ways, but the most frequent complaint is pain. The pain is usually located over the abdominal wall defect and is greatest at the fascial margins. It is usually dull in nature and typically does not radiate. Straining maneuvers may exacerbate symptoms or demonstrate a previously unnoticed defect. Patients may describe changes in bowel habits that can result from incarceration of abdominal viscera. The presence of an irreducible hernia should prompt surgical referral. Sharp pain or peritoneal signs suggest the possible diagnosis of strangulation with tissue necrosis; urgent surgical referral is necessary.

The diagnosis is made by physical examination. Findings may include a visible bulge or palpable fascial edges. The size and number of fascial defects are often difficult to determine preoperatively. Usually, the clinical exam represents the "tip of the iceberg"; additional fascial defects not appreciated preoperatively are often identified at surgery. A palpable mass in a suspected incisional hernia should not be aspirated since this mass may contain bowel.

 

Diagnosis

CT is useful in the diagnosis of external hernia at unusual sites, particularly in patients with obesity. The technique can demonstrate visceral hernial contents and complications such as vascular compromise. The diagnosis of an internal hernia is always based on radiologic findings, and CT is useful in depicting the precise site and type of hernia and its contents. \

Unlike other radiologic techniques, ultrasonography may be used to assess peristalsis. Close to the site of an obstruction, the distended bowel loses its muscular activity, whereas more proximally, peristaltic activity may be marked in cases of acute obstruction. These features help to differentiate a mechanical obstruction from the adynamic ileus of the postoperative state or peritonitis.

 

Risks for post-operative hernia development

•   Vertical scar more commonly affected than horizontal

•   Wound infection

•   Wound dehiscence

•   Malnutrition

•   Obesity

•   Tobacco abuse

 

Signs

•   Provocative maneuvers to locate hernia

    -  Hernia sac will appear adjacent to scar

    -  Hernia sac may be obvious with patient standing

    -  Valsalva maneuver

    -  Raise head from pillow while supine

•   Large incisional hernias are often asymptomatic

•   Often multiple defects present with several rings

•   Often Irreducible Hernia due to adhesions

 

Complications

•   Incarcerated Hernia is common

•   Strangulated Hernia is rare

 

Pathophysiology

•   During conventional open surgery an opening is made in abdominal layers which are closed by stitches.

•   With time scar tissue forms creating a bond between the two sides of the previous incision.

It is never as strong as normal tissue and can tear and. When the scar tissue gives way an incisional hernia, peritoneum protrudes, forming the sac.

•   Wound infection after surgery is a common cause of incisional hernia because infection interferes with the normal healing process, result is a weaker scar.

•   Obesity, smoking, malnutrition, deficiency of vitamins chronic cough after operation, weight lifting after operation also contribute to hernias because they also interfere in normal tissue healing.

 

 Transverse Incisions

•   The complication rate of abdominal herniation following abdominal incisions approximates 4-10% (Larson, 1984). Postoperative wound infection and dehiscence increase the risk of ventral herniation. Other predisposing factors include patient age, type of incision, obesity, malnutrition, anemia, and steroid dependence (Poole, 1985). Transverse incisions course parallel to the relaxed skin tension lines of the abdominal wall and tend to heal as thinner, flatter scars as less tension is present on these wounds (Wilhelmi, 1999; Kraissl, 1951; Conway, 1938; Borges, 1984).

•   Accordingly, transverse incisions have the lowest rate of herniation compared with midline and paramedian incisions (Carlson, 2000). Lateral traction of the external oblique, internal oblique, transversus, and rectus muscles places tension on the fascia at the linea alba and on the skin to increase risk of skin and fascial dehiscence. Increased intra-abdominal pressure as observed with chronic lung disease, coughing, or ascites also can contribute to the risk of incisional hernia. Repair of incisional hernias usually can be performed in a single stage unless an intraoperative complication is encountered

 

Primary vs. Mesh

•   Incisional hernia is a frequent complication of abdominal surgery. In prospective studies with sufficient follow-up, primary incisional hernia occurred in 11 to 20 percent of patients who had undergone laparotomy. (1,2,3) Such hernias can cause serious morbidity, such as incarceration (in 6 to 15 percent of cases) (4,5) and strangulation (in 2 percent). (4) If the hernia is not reduced promptly, small bowel that is strangulated in the hernia may become ischemic and necrotic and perforation may ultimately occur. Although many techniques of repair have been described, the results are often disappointing. After primary repair, rates of recurrence range from 24 percent to 54 percent. (4,6,7,8,9) Repairs that include the use of mesh to close the defect have better but still high recurrence rates, up to 34 percent. (8,10) After repair of recurrent incisional hernias, recurrence rates of up to 48 percent have been reported. (5) These studies of suture repairs and mesh repairs, however, were either uncontrolled or nonrandomized, and it remains uncertain whether mesh repair is superior to suture repair. To define the indications for the use of mesh materials, we undertook a randomized, multicenter study of patients with midline abdominal incisional hernias.

•   Results. Among the 154 patients with primary hernias and the 27 patients with first-time recurrent hernias who were eligible for the study, 56 had recurrences during the follow-up period. The three-year cumulative rates of recurrence among patients who had suture repair and those who had mesh repair were 43 percent and 24 percent, respectively, with repair of a primary hernia (P=0.02; difference, 19 percentage points; 95 percent confidence interval, 3 to 35 percentage points). The recurrence rates were 58 percent and 20 percent with repair of a first recurrence of hernia (P=0.10; difference, 38 percentage points; 95 percent confidence interval,-1 to 78 percentage points). The risk factors for recurrence were suture repair, infection, prostatism (in men), and previous surgery for abdominal aortic aneurysm. The size of the hernia did not affect the rate of recurrence.

•   Conclusions. Among patients with midline abdominal incisional hernias, mesh repair is superior to suture repair with regard to the recurrence of hernia, regardless of the size of the hernia. (N Engl J Med 2000;343:392-8.)

 

Laparoscopic

What are the advantages of laparoscopic hernia repair?

Laparoscopic approach has several advantages:

1.  Tension free repair.

2.   Less tissue dissection and disruption of tissue planes

3.   Less pain postoperatively.

4.   Low intra-operative and postoperative complications.

5.   Early return to work

 

References:

  1. Abdominal Wall Reconstruction Author: Bradon J Wilhelmi, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Southern Illinois University School of Medicine

  2. Hernia Author: Mark A Mullins, MD, Staff Physician, Department of Emergency Medicine, University of Virginia

  3. Small Bowel Obstruction Author: Ali Nawaz Khan, MBBS, FRCP, FRCR, Lecturer, Department of Diagnostic Radiology, Faculty of Medicine, University of Manchester

  4. The New England Journal of Medicine -- August 10, 2000 -- Vol. 343, No. 6

  5. A Comparison of Suture Repair with Mesh Repair for Incisional Hernia

  6. Roland W. Luijendijk, Wim C.J. Hop, M. Petrousjka van den Tol, Diederik C.D. de Lange, Marijel M.J. Braaksma, Jan N.M. IJzermans, Roelof U. Boelhouwer, Bas C. de Vries, Marc K.M. Salu, Jack C.J. Wereldsma, Cornelis M.A. Bruijninckx, Johannes Jeekel 

 

Questions:

 

Answer Key:

 

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Last modified: 10/31/04