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Abdominal PainAbdominal Mass

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Presents to ER with one day history of sudden, worsening abdominal pain ... Enlarges over time leading to pain, bowel obstruction, incarceration, and strangulation ... – PowerPoint PPT presentation

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Title: Abdominal PainAbdominal Mass


1
Abdominal Pain/Abdominal Mass
  • Melissa L. Hughes
  • Scott Q. Nguyen, M.D.
  • Celia M. Divino, M.D.
  • Department of Surgery
  • Mount Sinai School of Medicine

2
HPI Mrs.Masseo
  • Mrs. Masseo is a 63-year-old female with PMH of
    HTN, DM, s/p laparotomy for peptic ulcer disease
    seven years ago
  • Presents to ER with one day history of sudden,
    worsening abdominal pain associated with nausea,
    two episodes of vomiting, and abdominal
    distension

3
  • What other information would you want regarding
    this patients history?

4
Other Pertinent HPI
  • Patient had noticed a bulging from her mid
    abdomen beneath the surgical scar for the past
    several months. It was not initially painful,
    became larger when she coughed, and would go away
    when she was lying down
  • After an acute coughing episode the morning prior
    to admission, patient reported that she suddenly
    experienced severe pain in her mid abdomen that
    was constant and accompanied by an increase in
    size of the midline bulge which did not go away
    when she tried to lie down
  • No flatus or bowel movement over the past day,
    several episodes of vomiting, and subjective
    fevers

5
Other Pertinent History
  • PMH Poorly controlled HTN and DM for the past 20
    years
  • PSH Appendectomy at age 35, laparotomy 7 years
    ago for PUD
  • Meds lisinopril, insulin, nexium, aspirin
  • Allergies NKDA
  • Social history 1.5 packs of cigarettes a day for
    the past 40 years

6
  • What would you look for on physical exam?

7
Physical Exam
  • Ill-appearing, obese woman in severe pain
  • BP 100/60 HR 115 Temp 38.2 C RR 24
  • HEENT oral mucosa dry
  • Heart tachycardic, regular rhythm
  • Lungs clear to auscultation bilaterally
  • Abdomen obese abdomen, healed midline
    laparotomy and RLQ scars, hypoactive bowel
    sounds, moderate distension, firm, tender
    softball size mass at midline scar with erythema
    of the overlying skin. No rebound or guarding in
    remaining abdomen
  • Guaiac positive stool

8
  • What is your differential diagnosis?

9
Differential Diagnosis
  • Incarcerated ventral hernia
  • Small/large bowel obstruction- secondary to
    adhesions, volvulus, neoplasm
  • Abdominal wall tumor
  • Abdominal wall abscess

10
  • What labs would you order?

11
Lab results, Mrs. Masseo
10
134
94
40

15
350
190


3.3
20
1.7
30.1
n 89 LFTs, amylase, lipase,
and coags- WNL
12
Lab Findings
  • Pre-renal azotemia secondary to dehydration
  • Leukocytosis from infection/inflammatory process

13
  • What imaging would you like to obtain?

14
Obstructive Series
15
Obstructive Series
Describe the X-ray findings
16
Xray Interpretation
  • No free air noted on CXR
  • No significant small bowel dilatation
  • Air in right colon
  • No small bowel obstruction

17
If this patient had bowel obstruction secondary
to an incarcerated loop of small bowel in the
ventral hernia, then why are there no signs of
small bowel obstruction on Xray?Is there
another study which may help?
18
CT Scan Mrs. Masseo
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24
CT Interpretation
  • Transverse colon incarcerated in ventral
    abdominal wall hernia
  • Soft tissue stranding in subcutaneous fat around
    incarcerated hernia
  • Absence of enteric contrast past area of
    incarceration with collapse of left colon
    consistent with complete large bowel obstruction

25
  • What would be your next step in management?

26
Hospital Course
  • Immediate resuscitation with IV fluids, foley
    catheter, NG tube decompression and pre-op
    antibiotics
  • Patient taken to the OR for incarcerated hernia
    with suspected strangulated bowel
  • Exploratory laparotomy performed using previous
    midline incision
  • Found to have ischemic loop of transverse colon
    twisted upon itself, herniating through a 4cm
    abdominal wall defect
  • Segment of ischemic bowel was resected and
    primary anastomosis performed
  • Hernia repaired primarily, skin was left open

27
Hospital Course
  • Patient did well post-operatively without
    complications
  • POD 4 regained bowel function
  • POD 6 tolerated normal diet
  • POD7 discharged home

28
  • What is the problem with repairing this patients
    hernia primarily? Would you want to use mesh in
    this situation?

29
Primary repair of Ventral (Incisional) Hernia
  • Recurrence of a ventral hernia is a common
    problem in primary suture repair, whereas repair
    with prosthetic mesh often has lower recurrence
    rates
  • However, in a patient with strangulated, ischemic
    bowel who undergoes a bowel resection, inserting
    mesh into a contaminated field increases risk of
    infection of the mesh and ultimate need for
    reoperation and removal

30
Follow-up
  • Patient seen at follow-up appointment 6 months
    later and was found to have another reducible
    hernia through the same 4cm abdominal wall defect
  • Patient denied any abdominal pain, distension,
    nausea, vomiting, or fevers

31
  • What would you do next to help this patient?

32
  • Discuss treatment options for repair of recurrent
    incisional hernias
  • Discuss pre-operative preparation

33
Follow-up
  • Patient taken back to the OR for elective ventral
    hernia repair
  • Open hernia repair performed using non-absorbable
    mesh in an under-lay fashion
  • Patient continues to do well two years after
    elective repair without any signs or symptoms of
    recurrence

34
Incisional Hernia Discussion
  • Hernias that occur at a prior abdominal incision
    site (includes post laparotomy hernias,
    parastomal hernias, and trocar site hernias)
  • Incisional hernias reported in up to 20 of
    patients undergoing laparotomy with modern rates
    ranging from 2-11
  • Approximately 100,000 ventral incisional hernia
    repairs performed each year in U.S.
  • Most present within 12 months post-laparotomy
    although as many as 1/3 may present 5-10 years
    later

35
  • What are the risk factors for developing an
    incisional hernia?

36
Risk Factors
  • Patient-related factors advanced age,
    malnutrition, diabetes mellitus, cigarette
    smoking, corticosteroids, conditions that
    increase intra-abdominal pressure like obesity
    ascites, or chronic cough
  • Surgery-related factors wound or intraabdominal
    infection, closure of abdomen under tension, type
    and location of incision (vertical midline
    incision more prone to incisional hernia than
    transverse), lack of mesh overlap at hernia edges
    (bridge technique)

37
Clinical Manifestations and Diagnosis
  • Bulge in abdominal wall at or near surgical scar
  • Discomfort aggravated by coughing or straining
  • Enlarges over time leading to pain, bowel
    obstruction, incarceration, and strangulation
  • In large hernias, the skin may present with
    ischemic or pressure necrosis resulting in
    ulceration
  • Usually easy to identify on exam, with palpable
    edges of fascial defect
  • In obese patients with suspected incisional
    hernias the surgeon should have a low threshold
    for obtaining a CT abdomen as the clinical exam
    is very unreliable

38
Treatment
  • Treatment includes two general types of operative
    repair primary suture repair and prosthetic mesh
    repair
  • Recurrence rates for non-prosthetic repair can be
    as high as 50 or more, whereas mesh repair is
    associated with significantly lower recurrence
    rates

39
Primary Repair
  • Usually performed for hernia defects less than 4
    cm in diameter, with strong, viable surrounding
    tissue using an interrupted layer of
    nonabsorbable sutures
  • Some studies have suggested that even these
    small hernias may have a substantially lower
    recurrence rate after mesh repair
  • Separation of components is a technique that
    utilizes the bodys own tissues for hernia
    repair, avoids the use of a foreign body, and in
    experienced hands may have very good results

40
Prosthetic Repair
  • For large hernias, or hernias associated with
    multiple small defects, mesh should be placed by
    open or laparoscopic approach
  • Mesh provides tension-free repair by avoiding the
    recreation of tension by fascial apposition. In
    large hernias with loss of domain , fascial
    apposition may not even be possible.
  • Much improved recurrence rates over primary repair

41
Prosthetic Repair
  • Many different prosthetic materials available
    today for hernia repair but limited evidence and
    comparative studies exist
  • Bioabsorbable meshes have become popular and may
    be used in an infected field but should not be
    regarded as permanent hernia repair as high rates
    of recurrence/ dilatation have recently been
    described
  • Many techniques for mesh placement (ex)
    Rives-Stoppa repair where mesh is placed in
    retrorectus space, laparoscopic repair with mesh
    placement intraabdominally behind the rectus and
    peritoneum, open in-lay, on-lay and under-lay
    mesh repairs.
  • Technique may be paramount in recurrence rates

42
Complications
  • Recurrence As high as 30-50 in primary suture
    repair, 5-35 in open mesh repair, and 0-11 in
    laparoscopic mesh repair
  • Wound infections are more common after open
    repair compared to laparoscopic
  • Mesh infection often necessitates removal of mesh
    but can occasionally be treated with IV
    antibiotics and local wound care
  • Erosion of mesh into bowel with development of
    enterocutaneous fistulas
  • Bowel obstruction/ileus

43
QUESTIONS ??????
44
References
  • Feldman LS, et al. Laparoscopic Hernia Repair.
    ACS
  • Surgery Principles and Practice. Chapter
    5, Section
  • 28. 2003
  • Fitzgibbons RF, et al. Open Hernia Repair. ACS
  • Surgery Principles and Practice. Chapter
    5, Section
  • 27. 2003
  • Townsend CM. Sabiston Textbook of Surgery. 17th
  • edition
  • Zinner, MJ, et al. Postoperative Ventral Wall
  • (Incisional) Hernia. Maingots Abdominal
    Operations.
  • Chapter 5. Hernias. 11th edition

45
  • Acknowledgment
  • The preceding educational materials were made
    available through theASSOCIATION FOR SURGICAL
    EDUCATION
  • In order to improve our educational materials
    wewelcome your comments/ suggestions at
  • feedbackPPTM_at_surgicaleducation.com
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