Incarcerated Hernias and Abdominal Wall Reconstruction

Incarcerated Hernias and Abdominal Wall Reconstruction

Michael C. Smith, MD1 and Richard S. Miller, MD2

1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA

2 Department of Surgery, TCU & UNTHSC School of Medicine, John Peter Smith Health, Fort Worth, TX, USA

  1. A 52‐year‐old man presents with abdominal pain and fever. He is found to have diverticulitis with feculent peritonitis, for which he undergoes sigmoidectomy. Which suture material is associated with the lowest rate of dehiscence for fascial closure of a midline laparotomy in a contaminated field?

    1. Looped polydioxanone (PDS)
    2. Triclosan‐coated looped PDS
    3. Polypropylene
    4. Braided polyester
    5. Barbed triclosan‐coated PDS

    In a recent multicenter, randomized controlled trial, a barbed, triclosan‐coated PDS suture outperformed both triclosan‐coated loop PDS and uncoated PDS. Previous studies have demonstrated improved outcomes with long‐term absorbable suture as compared to permanent suture. Both the monofilament nature of this suture as well as its antimicrobial coating are thought to decrease microbial colonization and thus fascial dehiscence.

    van’t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta‐analysis of techniques for closure of midline abdominal incisions. Br J Surg. 2002; 89(11):1350–1356. doi: 10.1046/j.1365‐2168.2002.02258.x. PMID: 12390373.

    Ruiz‐Tovar J, Llavero C, Jimenez‐Fuertes M, Duran M, Perez‐Lopez M, Garcia‐Marin A. Incisional surgical site infection after abdominal fascial closure with triclosan‐coated barbed suture vs triclosan‐coated polydioxanone loop suture vs polydioxanone loop suture in emergent abdominal surgery: a randomized clinical trial. J Am Coll Surg. 2020; 230(5):766–774. doi: 10.1016/j.jamcollsurg.2020.02.031. Epub 2020 Feb 27. PMID: 32113031.

  2. Which fascial closure technique is associated with a decreased rate of incisional hernia?

    1. Simple interrupted
    2. Continuous suture with > 4:1 suture: wound length ratio
    3. Interrupted figure of eight with retention suture
    4. Continuous, locked closure
    5. Continuous suture with internal retention suture

    B. Incisional hernia is a complication of laparotomy, with rates in excess of 20% at long‐term follow‐up. Of the listed techniques, a continuous suture, with a long‐term absorbable suture is preferable to the other options. This was highlighted by the STITCH Trial, which showed using a long‐term absorbable suture with 5 mm bites and 5 mm advancement resulted in a greater than 4:1 suture‐to‐wound length ratio and a significantly decreased rate of incisional hernia.

    Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double‐blind, multicentre, randomised controlled trial. Lancet. 2015; 386(10000):1254–1260. doi: 10.1016/S0140‐6736(15)60459‐7. Epub 2015 Jul 15. PMID: 26188742.

  3. When performing an incisional hernia repair with mesh, which mesh position is associated with the lowest risk of recurrence?

    1. Onlay
    2. Inlay
    3. Sublay
    4. Preperitoneal
    5. Underlay

    C. When performing a mesh repair, one may utilize the onlay (anterior to the anterior rectus sheath), inlay (sewn as a “bridge” between fascial edges), sublay or retrorectus (between the rectus abdominis muscle and posterior rectus sheath), preperitoneal (between the peritoneum and posterior rectus sheath), or underlay (intraperitoneal) techniques. In a meta‐analysis, the sublay or retrorectus mesh position was associated with the lowest rate of hernia recurrence. Though technically challenging, the preperitoneal repair may be useful in patients who have undergone multiple prior repairs.

    Sosin M, Nahabedian MY, Bhanot P. The perfect plane: a systematic review of mesh location and outcomes, update 2018. Plast Reconstr Surg. 2018; 142(3 Suppl):107S–116S. doi: 10.1097/PRS.0000000000004864. PMID: 30138278.

    Novitsky YW, Porter JR, Rucho ZC, Getz SB, Pratt BL, Kercher KW, Heniford BT. Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias. J Am Coll Surg. 2006; 203(3):283–9. doi: 10.1016/j.jamcollsurg.2006.05.297. Epub 2006 Jul 13. PMID: 16931299.

  4. A 54‐year‐old woman with a history of multiple incisional hernia repairs, both laparoscopic and open, presents for consideration of repair. Her defect at maximum width measures 15 cm. Which of the below may be injected into the abdominal wall musculature to facilitate a tension‐free approximation of the linea alba?

    1. Botulinum Toxin A
    2. Rocuronium
    3. Nitroglycerin
    4. Lidocaine
    5. Verapamil

    A. Botulinum Toxin A injection under ultrasound or EMG guidance can temporarily paralyze the abdominal wall musculature in the perioperative period. This may allow an increase in abdominal domain and thus less tension on the linea alba approximation when repairing a ventral hernia. Other techniques, such as pneumoperitoneum and tissue expanders, have also been utilized for this purpose.

    Motz BM, Schlosser KA, Heniford BT. Chemical components separation: concepts, evidence, and outcomes. Plast Reconstr Surg. 2018; 142(3 Suppl):58S–63S. doi: 10.1097/PRS.0000000000004856. PMID: 30138269.

  5. Which of the following is the most appropriate indication for the consideration of biologic mesh in place of synthetic mesh?

    1. Body mass index > 35 kg/m2
    2. Hemoglobin A1C > 8
    3. Contaminated operative field
    4. Recurrent hernia
    5. Colonization with methicillin‐resistant Staphylococcus aureus

    C. While all of the above choices raise the risk of surgical site occurrences and/or hernia recurrence, only the contaminated field merits the consideration for a repair with a biologic mesh over a synthetic mesh. Efforts to identify these risk factors and modify them preoperatively can reduce this risk.

    Rosen MJ, Bauer JJ, Harmaty M, Carbonell AM, Cobb WS, Matthews B, Goldblatt MI, Selzer DJ, Poulose BK, Hansson BM, Rosman C, Chao JJ, Jacobsen GR. Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: the COBRA study. Ann Surg. 2017; 265(1):205–211. doi: 10.1097/SLA.0000000000001601. PMID: 28009747; PMCID: PMC5181129.

    Liang MK, Goodenough CJ, Martindale RG, Roth JS, Kao LS. External validation of the ventral hernia risk score for prediction of surgical site infections. Surg Infect (Larchmt). 2015; 16(1):36–40. doi: 10.1089/sur.2014.115. PMID: 25761078; PMCID: PMC4363797.

  6. A 42‐year‐old woman presents with a recurrent incisional hernia. It measures 18 cm wide at maximum width. When performing a transversus abdominis release (TAR), where is the transversus abdominis incised?

    1. At the linea alba
    2. At the linea semilunaris
    3. Just medial to the neurovascular bundles
    4. Just lateral to the neurovascular bundles
    5. At the arcuate line

    C. To perform a transversus abdominis release (TAR), one first must incise the posterior rectus sheath just lateral to the linea alba and develop the retrorectus space. Upon reaching the neurovascular bundles, one must incise the transversus abdominis muscle to expose the underlying transversalis fascia. This dissection can then be continued laterally and posteriorly in order to achieve approximation of the linea alba and facilitate large mesh placement. This maneuver is not possible from the linea alba. If attempting this maneuver at the linea semilunaris or lateral to the neurovascular bundles, it would result in oblique muscle weakness.

    Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012; 204(5):709–716. doi: 10.1016/j.amjsurg.2012.02.008. Epub 2012 May 16. PMID: 22607741.

  7. A 32‐year‐old man undergoes a laparotomy for a gunshot wound to the liver. This is treated with packing and a temporary abdominal closure device is placed. Which of the following is an indication for abdominal wall closure?

    1. pH of 7.41
    2. Ongoing blood product requirements
    3. Peak inspiratory pressure of 42 cm H2O upon fascial approximation
    4. Core temperature 34 °C
    5. Escalating pressor dosage

    A. Damage control laparotomy is utilized in patients whose physiology is deranged to the point that an abbreviated laparotomy is deemed more appropriate. In this patient, packing in an attempt to control bleeding, with the potential for angioembolization, is an indication for a temporary abdominal closure. Once the underlying “lethal triad” of acidosis, coagulopathy, and hypothermia is corrected, closure is permissible. However, if the patient’s peak inspiratory pressure is elevated upon fascial approximation, then closure will cause the abdominal compartment syndrome.

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Incarcerated Hernias and Abdominal Wall Reconstruction

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