Mesh Repair In Acute Hernia Surgery Sam Hawkins PGY4 Downstate - - PowerPoint PPT Presentation

Mesh Repair In Acute Hernia Surgery

Sam Hawkins PGY4 Downstate

Case Presentation

• 72F
• HTN, DM, CAD s/p CABG, GERD
• Active MI, evolving AKI, respiratory de-

compensation

• Known umbilical hernia, report of acute

enlargement in past 24h

Case Presentation

• 98.7; 110/89; 86
• Intubated, sedated but arousable
• Abd obese, obvious umbilical bulge w/ ttp,

tense, skin w/ erythema

Case Presentation

• Labs:

– CBC: 29.68/7.7/24.7/547 – BMP: 135/3.7/100/23/44/3.51/239 – Trop: 2.6->5.1->12.8

Case Presentation

• To OR

– Exploration of hernia: omentum, large omental hematoma, small bowel, large bowel – Reduction of hernia contents without bowel resection – Excision of hernia sac – Swiss cheese fascia – extension of fascial incision to include other defects – Placement of underlay mesh with trans-facial sutures – Closure of fascia over mesh – Skin closure with staples

Case Presentation

• Post-op course

– POD 2 extubated – POD 2-7 BID dressing changes for moderate to significant serous drainage from staple line – POD 7 staple-line vac dressing placed, removed POD 14 – POD 22 staples removed – Pt currently in residence on telemetry, no recurrence or complications

?

Mesh Repair in Acute Hernia Surgery

• Mesh is great!
• Mesh = a non-native matrix of biologic or

synthetic material used to augment the surgical repair of native tissue defects

Q1: What is the principal psysiologic advantage to use of mesh in hernia repairs?

A. Increased inflammatory reaction leading to more dense adhesions within and around the fascial defect B. Decreased tension on fascial suture lines C. Increased post-operative pain deters patients from early activity and disruption of the repair D. A and B

Q1: What is the principal psysiologic advantage to use of mesh in hernia repairs?

A. Increased inflammatory reaction leading to more dense adhesions within and around the fascial defect B. Decreased tension on fascial suture lines C. Increased post-operative pain deters patients from early activity and disruption of the repair D. A and B

• Polemic
• Strongly in favor of use of mesh in

contaminated fields

• Represents a position paper on a subject that is

controversial

Proposition: Use of mesh in contaminated fields creates an unacceptable risk of wound infection that could necessitate mesh removal

Proposition: Use of mesh in contaminated fields creates an unacceptable risk of wound infection that could necessitate mesh removal

Real Question: I’m repairing a hernia that is acutely incarcerated or strangulated, should I use mesh or close primarily?

• NSQIP
• 33832 ventral hernia repairs with mesh

determined by CPT 49568

• 30106 ventral hernia repairs without mesh

determined by CPT codes 49560 or 49561

• Demographics and perioperative factors

compared

• 30 day follow-up

Q2: Which of the following statements is FALSE?

A. NSQIP stands for National Surgical Quality Improvement Program B. NSQIP started within the VA system before becoming an ACS spearheaded program involving non-VA hospitals C. All of the top 12 hospitals in the US News and World Report Best Hospitals ranking participate in NSQIP D. NSQIP participation is exclusive to US hospitals E. A participating hospital must hire a Surgical Clinical Reviewer (SCR) to collect preoperative through 30-day postoperative data on randomly assigned patients

Q2: Which of the following statements is FALSE?

A. NSQIP stands for National Surgical Quality Improvement Program B. NSQIP started within the VA system before becoming an ACS spearheaded program involving non-VA hospitals C. All of the top 12 hospitals in the US News and World Report Best Hospitals ranking participate in NSQIP D. NSQIP participation is exclusive to US hospitals E. A participating hospital must hire a Surgical Clinical Reviewer (SCR) to collect preoperative through 30-day postoperative data on randomly assigned patients

• Their analysis leaves out:

– Emergent vs elective – Mesh type: biologic vs synthetic – Mesh placement: onlay vs inlay vs underlay etc (see Praz) – >30d complication rate – Intervention for infection complication – Comparison of OR for mesh vs non-mesh

Real Question: I’m repairing a hernia that is acutely incarcerated or strangulated, should I use mesh or close primarily?

Outline

• Mesh vs No Mesh in Contaminated Cases –

The Parastomal Hernia

• Mesh in Contaminated vs Non-Contaminated

Cases

• Mesh in Acute Repairs
• Mesh in repairs coincident w/ GYN procedures

– there is nothing

• Parastomal Hernia

– Incisional hernia related to enterostomy – Incidence for colostomy 3%-39% – Incidence for ileostomy 0%-6% – Surgical treatment can involve:

• Relocation of the stoma
• Repair with mesh
• Repair without mesh
• Laparoscopic vs open approach

– Contaminated

• Meta-analysis
• Relocation excluded
• Weighted pooled cases:

– Suture repair: 106 – Onlay mesh repair: 157 – Retromuscular mesh repair: 42 – Open intra-peritoneal mesh repair: 45 – Laparoscopic repair: 338

Onlay Intra-peritoneal (Underlay) Retromuscular (Sublay)

Keyhole Sugarbaker

• Retrospective review
• 177 pts
• Mesh vs No Mesh in contaminated fields

• Retrospective review
• 163 pts
• Clean vs Contaminated using Mesh

• Retrospective review
• 100 pts
• Clean-contaminated vs Contaminated using

Mesh

A Comparison

• Xourafas et al – Mesh vs no mesh – USE

CAUTION

• Abd Ellatif et al – Contaminated vs Clean –

USE MESH

• Carbonell et al – Contaminated vs Clean-

Contaminated – USE MESH

• Prospective review – still descriptive
• 80 pts
• Their results vs ?

• All cesarean +/-

hernia repair

• Small study sizes
• Repair vs no repair
• No mesh

Conclusions

• Board answer: Contaminated Field = Primary

Repair

• Acute Hernia Surgery = OK for mesh (if no

contamination)

• Need more studies, good studies, BIG studies