6 7 •Midline incisions •Paramedian •Incisions lateral to the midline made with transverse or oblique orientations •McBurney incision for appendectomy •Subcostal incisions on the right (Kocher incision for cholecystectomy) or left (for splenectomy) •Pfannenstiel incision, used commonly for pelvic procedures, 8 Bookwalter, Omni-Tract and Thompson retractors
9 Diastasis recti
10 Diastasis recti
•Bulging of the abdominal wall in the
epigastrium •Mistaken for a ventral hernia
•Advancing age •After multiple or twin pregnancies •Surgical correction → plication of 11 the broad midline aponeurosis 12 Diastasis recti repair
13 Hernia
14 Ventral Hernia
•Ventral hernias Nonincisional
•Epigastric •Defects in the parietal abdominal •Spigelian hernias wall fascia and muscle •Umbilical –Abdominal wall incision → incisional hernia –10% of all newborns –Architectural deterioration of the –Common in premature infants musculoaponeurotic tissues –Most congenital umbilical hernias close spontaneously by 5 years. •Bulge on the anterior abdominal wall 1.Small, asymptomatic→follow clinically. •A hernia that cannot be reduced → 2.Primary sutured repair incarcerated 3.Placement of prosthetic mesh for larger defects •Localized ischemia → Strangulated, (>2 cm) using open or laparoscopic methods. 15 Ventral hernias Epigastric hernia
•Ramirez anterior components separation technique. •The net effect is up to 10 cm of medial mobilization •Permanent implant or biologic materials with components separation 26 27 Principles of the mesh deployment •Underlay - deep to the Diagrammatic representation of the fascial defect (intra- or planes within which prosthetic mesh preperitoneal) may be deployed and the correct •Interlay terminology associated with each –bridging the gap between placement. the defect edges a Onlay, – Between abdominal wall b Inlay or Interlay, musculoaponeurotic layers c Sublay, •Onlay - superficial to the d Underlay, fascial defect e Intraperitoneal 28 29 Ventral hernia repair Often it’s quite difficult to approximate edges of the hernia deffect. Therefore intraabdominal pressure on the mesh leads to dehiscence and failure.
Following methods are used to bring rectus muscles towards midline and place mesh endoprosthesis:
1. Anterior component separation (Ramirez)
2. Rives-Stoppa repair 3. Posterior component separation 4. Posterior component separation with TAR (Transversus abdominis release)
30 ① Anterior component separation (Ramirez)
31 Anterior component separation (Ramirez)
1. Skin flap development; 2. Transection of the external oblique aponeurosis; 3. Section of the posterior rectus sheath; 4. Fascial closure.
32 Anterior component separation (Ramirez)
33 ② Rives-Stoppa Repair
34 ②Rives-Stoppa repair
Pocket is created between the rectus muscle and Posterior rectus sheath is sutured 35 posterior rectus sheath ②Rives-Stoppa repair
Anterior rectus sheath is sutures
Mesh is placed between the rectus
muscle and posterior rectus sheath and fixed by trough sutures.
36 ②Rives-Stoppa
37 ②Rives-Stoppa
38 ②Rives-Stoppa
39 ③ Posterior Component Separation
40 Cutting most lateral ③ Posterior component part of the posterior rectus sheath pocket is separation created between posterior oblique and transversalis muscles.
Mesh is placed in that
pocket.
41 ③ Posterior Component Separation with TAR (transversus abdominis release)
42 ④ Posterior component separation with TAR (transversus abdominis release)
After performing the posterior component separation,
medial edge of the transversalis muscle is transected to make pocket between transversalis muscle and transversalis fascia. 43 The mish is placed in this pocket if necessary. 44 45 Mesh position after the posterior component seperation with TAR (Sublay)
“Posterior” component separation achieved by longitudinal incision
along the transversus muscles, the “Transversus abdominus release”. This repair has been strengthened by a mesh in the “sublay” position 46 Final overview of methods:
47 Diaphragmatic Herniation
48 Diaphragmatic Hernia Types 49 Diaphragmatic Anatomy and Hernia Types
50 Hiatal hernia
Hiatal hernia is the protrusion of the stomach Rrisk factors include:
and other abdominal viscera into the mediastinum ● Being overweight ● Elderly ● Multiple pregnancies ● History of esophageal surgery It is caused by increased intra-abdominal ● Partial or full gastrectomy pressure. ● Certain disorders of the skeletal system associated with bone decalcification and degeneration
51 Lower Esophageal Sphincter
52 53 54 Axial Paraesophageal high risk of gastric obstruction.
55
90% 4.5% Hiatal hernia
● Type I hernias represent more than 90% of Gastroesophageal reflux disease and hiatal cases of hiatal hernia and are known for hernia are closely associated their frequent association with GERD. They are also associated with more severe degrees of esophagitis and Barrett’s Regurgitation and heartburn esophagus Less common symptoms:
● Dysphagia ● Types II-IV are referred to as ● Epigastric or chest pain paraesophageal hernias (PEH); their main ● Chronic iron deficiency anemia clinical importance is due to their potential ● Early satiety for ischemia, obstruction or volvulus
56 Hiatal hernia
● Barium swallow still remains essential in the diagnosis of hiatal hernia →
video-esophagram. detecting esophageal motility dysfunction, stenosis and stricture related to GERD. ● Esophagogastroduodenoscopy (EGD) - check mucosa, erosive esophagitis, Barrett’s ● esophagus, Cameron’s ulcer and even lesions suspicious for malignancy. Air insufflation of the stomach may exaggerate hernia size, difficulty to assess massive hernias accurately ● Manometry rule out achalasia or other motility disorders. ● pH testing is not essential → to document acid reflux ● CT is not routinely recommended 57 58 Treatment
59 Treatment Of Axial Hiatal Hernia American College of Gastroenterology
The aim is to reduce the symptoms of ● 8-week course of PPI
gastroesophageal reflux disease: ○ Twice-daily PPI therapy if inadequate symptom response to once-daily PPI ● Lifestyle modifications: ○ Use the minimal dose of PPI that is ○ weight loss, sufficient to control symptoms ○ elevating the head of the bed by 8 ● Histamine 2 receptor antagonists inches during sleep, ● Antacids. ○ avoidance of meals 2-3 hours before ● bedtime, ○ elimination of “trigger” foods such as ■ chocolate, ■ alcohol, ■ caffeine, ■ spicy foods, ■ citrus, 60 ■ carbonated drinks Treatment Of Paraesophageal Hiatal Hernia American College of Gastroenterology
● Paraesophageal hernias⇨the gastric fundus has migrated above the
diaphragm ⇨ high risk of obstruction. ● Most of the patients experience little or no relief with medication ● Definitive treatment for paraesophageal hernia remains surgery.
Crurorraphy Fundoplication 61 Surgical treatment
● Do not repair type I hiatal hernia in ● The current standard procedure is
the absence of reflux disease and crurorraphy + laparoscopic symptoms; fundoplication for both sliding and ● Hiatal hernia repair can be combined paraesophageal hernia. with other types of bariatric surgery, ● Usually, a Nissen fundoplication such as sleeve gastrectomy and (360°) is performed after most hiatal gastric bypass. hernia repairs, ● Approach: ● Preexisting esophageal dysmotility, ○ Transabdominally in which case the Toupet ○ Transthoracic approach, usually fundoplication (270°) is preferred. through the left chest.
62 63 ● Use of mesh during paraesophageal hernia repair is controversial. ● Synthetic and biologic mesh ● Synthetic mesh⇨development of esophageal erosion, stricture, dysphagia, obstruction and esophageal stenosis Lower recurrence rate is associated with short-term follow-up for biologic mesh reinforcement 64 Fundoplication
● Patient satisfaction 15 years – 85%
● Durability = 80-90% at 15 years, 75% at 20 years ● Medication use in up to 40% 5 yrs post op ● Problems: ○ gas-bloat 5-34% ○ dysphagia 3-17% ● Prolonged recovery
