De Abdominale wand

22

Anterieure buikwand

33

SkinFat

Rectus Abdominis Rectus

Abdominis

E.A.O

.I.A.O.

T.A.

44

55

Hernia

66

3 Delen

1/ Breukinhoud

2 /Breukpoort

3 /Breukzak

77

Overview

1) Epigastric

2) Diastasis

3) Supra-umbilical hernia

4) Umbilical hernia

5) Incisional hernia

8) Spigelian hernia

9) Femoral hernia

10) Inguinal hernia

11) Pubic bone

12) Inguinal ligament

88

Definities

Reduceerbare hernia: spontaan of door manuele druk

terug te duwen in de buikholte

Niet-reduceerbare of geincarcereerde hernia: inhoud kan

niet teruggeduwd worden

≠ obstructie

≠ strangulatie

99

Hernia inguinalis – Anatomie (1)

Liesregio (groin)

Fascia transversalis

Ligamentum inguinale (Poupart)

Ligamentum pectineale (Cooper)

Conjoint tendon (falx inguinalis)

Fascia MOAE en MOAI

Ruimte van Bogros

Skandalakis JE et al. World J Surg 1989;13:490

1010

Direct versus indirecte hernia

1111

Hernia femoralis

4x meer bij vrouwen dan bij mannen

Altijd controle bij repair van een liesbreuk

33% van de breuken bij vrouwen, 2% bij de man

Meer strangulatie

Onder het ligamentum inguinale

Repair: ver schillende mogelijkheden met sluiten van het femoraal kanaal

1212

1313

Current guidelines (EHS 2009)

• Lichtenstein tension free repair reported recurrence

rates of 1-2%, although underestimated.

• Easy to perform at relatively low cost.

• Laparoscopic repair (TAP and TEP) reports low

recurrence rates and very quick recovery to normal

daily recovery.

So, why look for other techniques ?

1414

Lichtenstein

Referentie

Anterieur herstel

Tension free - prothese

Recidieven 1 à 2 %

Chronische pijn

Niet voor femoraalbreuken

1616

Lichtenstein : chronische pijn

Grondige fixatie

Mesh ligt op de inguinale

zenuwen

Reconstructie van een

interne liesring

1717

Anterieur - posterieur

1818

Preperitoneaal herstel

Prothese blijft ter plaatse door abdominale druk

Geen contact met oppervlakkige zenuwen

Grote overlap

1919

laparoscopie

TAPP

Trans abdominal pre-peritoneal repair

Toegang preperitoneaal via de abdominale caviteit met openen van peritoneum

TEP

Totally extra-peritoneal repair

Preperitoneale ruimte wordt bekomen zonder peritoneum te openen.

2020

laparoscopie

2121

Film TAPP

2323

Open preperitoneaal herstel:

2424

Final position of the mesh:

2525

Hernia umbilicalis

Meer bij vrouwen

Risicofactoren: zwangerschap, ascites, obesiteit

Kinderen: kan verdwijnen in de eerste levensjaren

Volwassenen: chirurgisch herstel

Repair: primair kan bij breukpoorten tot 1cm

Groter dan 1cm: prothese

Laparoscopisch of open

Igv cirrhose: geen consensus over mesh of geen mesh

Eerst controle over de ascites om genezing te bekomen

2626

2727

Closure of the defect

Mayo technique (double layer)

Spitzy technique

Single layer

Non-resorbable vs. resorbable suturematerial

No mesh vs. mesh

Open vs. laparoscopic

2828

Subumbilical incision

2929

Dissection around the sac down

to the aponeurotic layer

3030

Opening the sac/reposition of its content

3131

Removal of the sac

3232

Closure of the fascia

3333

3434

Fixation of the umbilicus to the fascia

3535

RCT comparing Suture vs. Mesh repair of umbilical hernias in adults:

Arroyo et al. Br J Surg 2001, 88, 1321-1323

Sutures Mesh

n 100 100

Hernia defect > 3 cm 30 32*

Hernia defect < 3 cm 70 68**

Recurrence rates 11% 1%

Hernia defect > 3 cm 13%

Hernia defect < 3 cm 10%

* Flat mesh

** Mesh Plug

No significant difference between recurrence rates for defects smaller

or greater than 3 cm

Primary ventral hernias

3636

Primary ventral hernias

Mesh is no longer optional, not even for defects smaller

than 1cm

Which mesh?

What position?

3737

Problems with safe placement….

Problems with good tissue ingrowth….

Problems with recurrences….

Intraperitoneal devices

3838

Safe placement might be a serious problem

Inflammatory reaction , mesh contraction

No “ideal” device has been developed yet….

Limit your hernia size to 2cm or less for such devices

Or is tailoring: going back to preperitoneal mesh

reinforcement with flat mesh??

Caution is warranted….

3939

Film umbilical met mesh

4040

Incisionele hernia (1)

10% na laparotomie

Slechte sluitingstechniek

Multiple ingrepen

Wondinfecties

Leeftijd

Onderliggend lijden

Obesiteit

Pulmonale complicaties postoperatief

4141

Herstel steeds middels mesh-placement

Verschillende technieken:

Rives-Stoppa (sublay), inlay, onlay etc.

Component separation techniek

Ramirez-incisies

Laparoscopisch: geen verwijderen van de breukzak

Gebruik van suturen aan te raden

Cave: seroomvorming!!

Incisionele hernia (2)

4242

Incisional hernias: incidence

31,5% in the first 6 months

54,4% after 12 months

74,8% after 2 years

88,9% after 5 years

Höer J et al. Factors influencing the development of incisional hernia. A retrospective

study of 2983 laparotomy patients over a period of 10 years. (2002) Chirurg; 73:474-480

4343

Techniques of repair

Primary repair

Prosthetic mesh repair

Onlay mesh repair

Inlay mesh repair

Retrorectus mesh repair

Intraperitoneal underlay mesh repair

4444

4545

Primary repair

For small defects < 5 cm

Continuous or interrupted sutures to approximate the

edges of the fascial defects (1 cm of the fascial edge 1

cm advancement) = Mayo repair

Recurrence rates > 50 %

Always tension on the repair

NOT DONE ANYMORE

4646

Prosthetic mesh repair

Onlay mesh is sutured to the anterior rectus sheath,

after primary closure of the fascial defect

Advantage

Mesh not in contact with abdominal content

Disadvantages

Repair under tension

Large subcutaneous dissection > seroma formation > mesh

infection

4747

Prosthetic mesh repair

Onlay only (no primary closure of fascial defect)

Advantage

Less tension

4848

Prosthetic mesh repair

Inlay mesh repair

Hernia sac is excised

Recurrence rates 30 – 40 %

Only when retrorectus or intraperitoneal mesh repair is not

possible

4949

Prosthetic mesh repair

Retrorectus mesh repair = Stoppa

Hernia sac in place as a buffer

Above umbilicus

Dissection above posterior rectus fascia and underneath the rectus

muscle

Below the umbilicus

No posterior rectus fascia, dissection in preperitoneal space

5050

Prosthetic mesh repair

Retrorectus mesh repair = Stoppa

Polypropylene mesh in space created and fixated to the muscle

layer above with full or partial thickness sutures

Recurrence rate < 10 %

Mesh infection 5 - 12 %

Pain > 10 %, usually resolves after complete ingrowth of the

mesh

5151

Rives-Stoppa

5252

Prosthetic mesh repair

Intraperitoneal underlay mesh repair

Open

Opening hernia sac, adhesiolysis and fixation of the mesh

intraperitoneal

Laparoscopic

Entering abdomen away from the defect, mesh fixed to the

abdominal wall with partial thickness tacks or full thickness

abdominal/fascial wall sutures

5353

Prosthetic mesh repair

Intraperitoneal underlay mesh repair

Laparoscopic

Significant seroma rate 10 – 15 %

Unrecognized bowel injuries

Recurrence rate < 5 %

5454

Film LVHR

5555

Rationale of Defect Closure

Promote tissue ingrowth into entire surface of mesh

Improve overall outcome

Lower recurrence rates

Lower seroma rates

Improvement of body image

5656

Influencing factors for tailoring

Hernia related factors

Patient related factors

Surgeon related factors

Choice of fabric

Available evidence

Surgeon

Technique

PATIENT

Choice of mesh

5757

Experience (lap vs. open; onlay versus sublay; suture

vs. mesh)

Favorism (for company, i.e. sales rep, laparoscopy etc.)

Belief (augmentation vs. bridging, closure of the defect

or not ….)

Cost-effectiveness (in function of hospital costs, patient

reimbursement etc.)

Surgeon related factors ~ available evidence

5858

Tailoring towards laparoscopic repair?

Cosmetic results?

Obesity?

Recurrent hernias

5959

Why an open repair?

Benefits

Ease of acces peritoneal

cavity

Familiarity with lysis of

adhesions

Ease of concomitant

operation

Mesh introdiction

Midline fascial closure

Scar excision

Disadvantages

Wound complications

Mesh complications

Complexity of techniques

Retromuscular space

Component separation

Pain

(Cosmesis)

6060

Why a laparoscopic repair?

Benefits

Decreased wound complications!

Easier exploration of the whole scar

Simplicity of mesh placement (POM)

Shorter hospital stay?

Cosmesis

Pain?

Disadvantages

Safe acces to multiply operated abdomen

Incarcerated hernia contents

Mesh introduction

Complexity of mesh fixation

Mesh-bowel adhesions

Missed enterotomy

Bridged repair

More expensive material

Trocar site hernias

Bulging

6161

Bedankt voor uw aandacht…..