Challenges and Management Strategies of Hernia in the obese.

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• HERNIA IN THE OBESE !!!
• Challenges n Management Strategies
• HERNIACON 2013 _at_AHEMADABAD

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WEL -COME

• Dr Sumeet Shah ,Delhi
• Dr Apoorva Vyas , Ahemadabad
• Dr Chirag Desai , Ahemadabad
• Dr Parag Khandelwal ,Ahemadabad
• Dr Sunil Popat ,Ahemadabad
• Dr Jayasshree Todkar , Pune

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• IS IT REALLY DIFFERENT ???

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48 yr old, DM on OHAs, HT, V.V with ulcers, Abd
hernia, Chronic smoker, Breathless on slight
exertion.
Target Leg ulcers to heal, Leg edema to be
less, Breathlessness less, Drugs less, Play with
children
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POPULAR BA SX IN INDIA
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• INCIDENCE
• ETIOLOGY

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Ventral HerniaIncisional Hernia

• Over 10,000 cases in India annually
• Incidence 211 of all the laparotomies,
  1520 after abdominal surgery in the obese,
  23 of the infected incisions
• Risk factors obesity, aged, anemia, smoking,
  infection, history of operation, long incision,
  incision site, emergency operation, increasing
  IAP, diabetes mellitus, some drugs
• Recurrence 1050

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Ventral HerniaUmbilical Hernia

• Umbilical hernia in adults
• Acquired umbilical hernia
• Increased IAP obesity, heavy lifting
• Long history of coughing
• Multiple pregnancies
• Three times more common in women
• Higher risk of strangulation

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Etiology

• Various factors are responsible
• More than one factor may co-exist in a given
  patient
• Poor Surgical technique
• Inadequate fascial bites
• Tension of fascial edges
• Tight closure
• Post-op wound infection
• Age slower in old age
• General debility, Cirrhosis, Carcinoma, Chronic
  Wasting disease
• Obesity
• Post-Operative Pulmonary Complications
• Intra Operative blood loss more than 1000ml
• Failure to close fascia of trocar sites over 10mm
  size

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Why Hernia repair is required ?

1. Associated morbidity secondary to incarceration,
   strangulation
2. Relative loss of abdominal domain with adverse
   effects on postural maintenance, respiration,
   micturition , defecation
3. Patients are forced to alter their lifestyle,
   their ability to work becomes impaired
4. A cosmetic deformity, detrimental to patients
   self-esteem

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Methods of repair

1. Primary Suture Repair
2. Mesh Repair by Open technique
3. Component separation
4. Flap reconstruction
5. Tissue expansion
6. Laparoscopic method
7. Combination of any methods

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Open Mesh Repair

• Use of synthetic mesh in Ventral Hernia Repair
  has increased since 1987
• Advantages
• Tension free restoration of structural integrity
  of the abdominal wall
• Easy availability ( thanks to industry )
• Absence of donor site morbidity
• Ideal Prosthesis should be
• Non-toxic
• Non-immunogenic
• Non-reactive
• Should get incorporated into the surrounding
  tissue
• Tensile strength is rarely a problem with
  available materials
• Failures with mesh occurs Laterally at mesh
  tissue interface

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Laparoscopic Repair

• Gaining Popularity
• Prosthetic material is placed in pre-peritoneal
  space or subperitoneal space ( i.e. Intra
  peritoneal Onlay Mesh Repair )
• Large prosthetic support is secured with
  transfixing sutures or tackers
• Sutures are placed at 4-5cm distance
• Tackers are placed at 1cm distance
• Alone tackers may lead to recurrence thus few
  transfixing sutures required

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Advantages

1. All advantages of minimally access surgery
2. Intra abdominal adhesion can be separated
3. If enterotomy or serosal injury can be sutured
4. Mesh placement to be delayed if enterotomy but
   later on, can be completed laparoscopically
5. Multiple hernias ( swiss cheese defects ) can be
   tackled

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Advantages open method over lap

1. Seromas
2. Potential risk to intestinal injuries
3. Bleeding from abdominal wall vessels
4. Pain due to tackers transfixing Sutures
5. Open repair provides opportunity to revise
   scarred abdomen abdominoplasty in selected
   cases
6. Cost

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BARIATRIC SURGERY N HERNIA REPAIR

• TECHNIC OPEN / LAP

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• Open technique

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Laparoscopic Technique
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BARIATRIC SURGERY N HERNIA REPAIR

• PORT POSITION, PATIENT POSITION

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Ventral HerniaIPOM

• Different choice of trocar site base on hernia
  site
• Lateral abdomen

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PORT POSITION
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Biomaterials

• Synthetic Nonabsorbable
• Coated Nonabsorbable
• Partially absorbable
• Biological

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Synthetic Nonabsorbable

• Polypropylene - causes intense inflammation
• - causes adhesions
• Polyesters - degradable ?
• PTFE - no invasion of tissues
• - encased in fibrosis
• - more shrinkage
• - more prone to
  infection ?

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Coated Nonabsorbable(Polypropylene)

• C Qur polypropylene coated with omega 3 fatty
  acids does not cause adhesions for 120 days ?
• Glucamesh - coated with oat beta glucan
• Timesh titanium coated causes collagen 1
  synthesis ?

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Prosthesis With Absorbable Barrier

• Sepramesh
• Macro porous polypropylene coated on one side
  with a bio-resorbable. Nonimmuogenic membrane of
  sodium hyaluronate and Carboxymethyl cellulose on
  the other side.
• Parietex
• Multifilament polyester mesh with a purified,
  oxidized bovine atelesllagen type I coating
  covered by an absorbable, antiadhesion film of
  polyethylene glycol and glycerol.
• Parientene
• Polypropylene coated with same anti adhesive
  barrier as above.

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• Proceed Surgical Mesh
• Lightweight monofilament polypropylene mesh
  encapsulated with laminated of polydioxanone
  coated on one side with the absorbable barrier
  material oxidized regenerated cellulose.

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v. Bard Composix MeshIt is a non absorbable
barrier mesh constructed of macro porous
polypropylene on one side bonded to low porosity
PTFE on the other side.

• GORE TEX Dual Mesh It has two surfaces one is
  very smooth micro porous to face visceral organs
  and other rough surface for tissue in-growth.

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Operating Factors Influencing Mesh Choice
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Targets Dreams achieved!
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Targets Dreams achieved!
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• REVIEW OF LITERATURE

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Comparison of early outcomes for laparoscopic
ventral hernia repair between nonobese and
morbidly obese patient populations. Surg
Endosc.2008 Oct22(10)2244-50. Epub 2008 Jul
12.Ching SS, Sarela AI, Dexter SP, Hayden JD,
McMahon MJ.

• CONCLUSION No significant difference in the
  incidence of peri operative complications or
  recurrence after LVHR was observed between the
  morbidly obese patients and the non-morbidly
  obese patients.

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Management of ventral hernias during laparoscopic
gastric bypass.Surg Obes Relat Dis. 2008
Nov-Dec4(6)757-8.Datta T, Eid G, Nahmias N,
Dallal RM.

• The only predictor for an increased length of
  hospital stay was hernia repair with mesh (odds
  ratio 9.2, P .002). The average follow-up was
  14 months (range 4-30 months). Of the 8 patients
  who had undergone primary repair, 2 presented
  with a postoperative small bowel obstruction at
  the site of their VHR. None of the patients who
  underwent VHR with prosthetic mesh developed an
  obstruction or clinical evidence of recurrence or
  infection

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Outcome of laparoscopic ventral hernia repair in
morbidly obese patients with a body mass index
exceeding 35 kg/m2Surg Endosc 2007
Dec21(12)2293-7. Raftopoulas I, Courculas AP

• CONCLUSIONS For morbidly obese patients, LVHR is
  safe and effective, but it is associated with
  higher likelihood of recurrence, and patients
  should be appropriately informed.

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Repair of ventral hernias in morbidly obese
patients undergoing laparoscopic gastric bypass
should not be deferred.Surg Endosc.2004
Feb18(2)207-10 Schauer PR et al.

• CONCLUSION Biomaterial mesh (SIS) repair of
  ventral hernias concomitant with LRYGB resulted
  in the most favorable outcome albeit having short
  follow-up. Concomitant primary repair is
  associated with a high rate of recurrence. All
  incarcerated ventral hernias should be repaired
  concomitant with LRYGB, as deferment may result
  in small bowel obstruction.

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Staged hernia repair preceded by gastric bypass
for the treatment of morbidly obese patients with
complex ventral hernias.Newcomb WL, Polhill JL,
Chen AY, Kuwada TS, Gersin KS, Getz SB, Kercher
KW, Heniford BT. 2008 Oct12(5)465-9

• CONCLUSION Gastric bypass prior to staged
  ventral hernia repair in morbidly obese patients
  with complex ventral hernias is a safe and
  definitive

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CONCLUSION

• Concomitant repair of ventral hernia with
  bariatric surgery is safe. Deferred treatment
  predisposes to higher complication rate.
• Prosthetic repair is better than primary repair
• Biological, dual, PTFE or other composite meshes
  can be safely used
• In selected cases judicious use of surgeons
  discretion is warranted.

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BARIATRIC SURGERY N HERNIA REPAIR

• ? SIMULTANAEOUS WHEN
• WHEN NOT
• ? NOT SIMULTANAEOUS HERNIA FIRST
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  BARIATRIC FIRST
• WHEN IS THE RIGHT TIME FOR SECOND PROCEDURE
• TECHNIC OPEN / LAP
• ANATOMICAL / MESH REPAIR
• PORT POSITION, PATIENT POSITION
• MESH CHOICE
• FIXATION DEVICE
• SPECIAL PRECAUTIONS
• TYPICALLY SIGNIFICANT SITUATION HIATUS
  HERNIA / INT HERNIA
• DRAIN OR NOT ?
• DOES HERNIA INFLUENCE THE TYPE OF BA SX
  PROCEDURE TO BE DONE

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BARIATRIC SURGERY N HERNIA REPAIR

• ? SIMULTANAEOUS WHEN
• WHEN NOT

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BARIATRIC SURGERY N HERNIA REPAIR

• ? NOT SIMULTANAEOUS
• HERNIA FIRST
• BARIATRIC FIRST

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BARIATRIC SURGERY N HERNIA REPAIR

• WHEN IS THE RIGHT TIME FOR SECOND PROCEDURE

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BARIATRIC SURGERY N HERNIA REPAIR

• ANATOMICAL
• when
• why
• MESH REPAIR
• when
• why

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BARIATRIC SURGERY N HERNIA REPAIR

• MESH CHOICE
• FIXATION DEVICE

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BARIATRIC SURGERY N HERNIA REPAIR

• SPECIAL PRECAUTIONS

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BARIATRIC SURGERY N HERNIA REPAIR

• TYPICALLY Special considerations
• HIATUS HERNIA
• INTERNAL HERNIA

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BARIATRIC SURGERY N HERNIA REPAIR

• DRAIN OR NOT ?

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BARIATRIC SURGERY N HERNIA REPAIR

• DOES HERNIA INFLUENCE THE TYPE OF BA SX
  PROCEDURE TO BE DONE

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• THANK YOU
• jayatodkar_at_gmail.com , 919823090505