Health-Process-Evidence-based Clinical Practice Guidelines on Incisional Hernias

1. Health-Process-Evidence-based Clinical Practice Guidelineson Incisional Hernias by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center

2. Clinical Questions • What is an operational concept of hernias? Ans: a protrusion of a viscus through an opening in the wall of the cavity in which it is contained.

3. Clinical Questions 2. What are the general categories of hernia? Ans: Groin Hernias Abdominal Wall Hernias Perineal Hernias Intraabdominal Hernias Diaphragmatic Hernias

4. Clinical Questions 3. What are the sub-categories of groin hernias? Ans: Inguinal Hernias - direct - indirect Femoral Hernias

5. Clinical Questions 4. What are the sub-categories of abdominal wall hernias? Ans: Incisional Hernias Peristomal Hernias Omphalocele Gastroschisis Umbilical Hernias

6. Clinical Questions 4. What are the sub-categories of abdominal wall hernias? (contd) Ans: Epigastric Hernias Spigelian Hernias Interparietal Hernias Supravesical Hernias Lumbar Hernias

7. Clinical Questions 4. What are the sub-categories of abdominal wall hernias? (contd) Ans: Obturator Hernias Sciatic Hernias

8. Clinical Questions 5. What are the sub-categories of perineal hernias? Ans: Perineal Hernias Prolapse of the Rectum

9. Clinical Questions 5. What are the sub-categories of intraabdominal hernias? Ans: Mesenteric Hernias Retroanastomotic Hernias Paraduodenal Hernias Hernias of the Broad Ligament

10. Clinical Questions 6. What are the sub-categories of diaphragmatic hernias? Ans: Paraesophageal Hiatal Hernias Congenital Diaphragmatic Hernias Traumatic Diaphragmatic Hernias

11. Clinical Questions 6. What is an operational concept of incisional hernias? Ans: any abdominal wall gap in a previous incision site, with or without a bulge, that is perceptible on clinical examination or imaging by 1 year after the index operation.

12. Clinical Questions 7. What are reliable symptoms and signs (more than 90% certainty) that will indicate that a patients has an non-incarcerated incisional hernia? Ans: on and off abdominal mass (with a concurrent abdominal wall gap in a previous incision site perceptible by imaging or physical examination by 1 year after the index operation)

13. Clinical Questions 8. What are reliable symptoms and signs (more than 90% certainty) that a patient has incarcerated incisional hernia? Ans: Abdominal mass Abdominal pain/tenderness over the defect, greatest along the fascial margins Irreducible (with a concurrent abdominal wall gap in a previous incision site perceptible by imaging or physical examination by 1 year after the index operation)

14. Clinical Questions 9. What are reliable symptoms and signs (more than 90% certainty) that a patient has strangulated incisional hernia? Ans: Abdominal mass Severe Abdominal pain/tenderness over the defect, greatest along the fascial margins Redness over the defect Irreducible (with a concurrent abdominal wall gap in a previous incision site perceptible by imaging or physical examination by 1 year after the index operation)

15. Clinical Questions 10.If an incisional hernia does not present with a bulge, how is it diagnosed? Ans: Detection of a defect in a previous incision site through physical examination

16. Clinical Questions 11. If a paraclinical diagnostic procedure is needed in a patient with suspected incisional hernia, what is the most cost-effective procedure? Ans: -abdominal ultrasound

17. Clinical Questions 12. How are incisional hernias classified? Ans: I. According to localization (modified Chevrel) Vertical 1.1. Midline above or below umbilicus 1.2. Midline including umbilicus right or left 1.3. Paramedian right or left Transversal 2.1. Above or below umbilicus right or left 2.2. Crossed midline or not

18. Clinical Questions 12. How are incisional hernias classified? (contd.) Ans: - Oblique 3.1. Above or below umbilicus right or left - Combined (midline + oblique; midline + parastomal; etc)

19. Clinical Questions 12. How are incisional hernias classified? (contd.) Ans: II. According to size Small (<5 cm in width or length) Medium (5-10 cm in width or length) Large (>10 cm in width or length)

20. Clinical Questions 12. How are incisional hernias classified? (contd.) Ans: III. According to recurrence Primary incisional hernia Recurrence of an incisional hernia (1., 2., 3., etc. with type of hernioplasty: adaptation, Mayo-duplication, prosthetic implantation, autodermal etc.)

21. Clinical Questions 12. How are incisional hernias classified? (contd.) Ans: IV. According to the situation at the hernia gate Reducible with or without obstruction Irreducible with or without obstruction

22. Clinical Questions 12. How are incisional hernias classified? (contd.) Ans: V. According to symptoms Asymptomatic Symptomatic

23. Clinical Questions 13. What are the common causes of incisional hernias? Ans: 1. poor surgical technique 2. use of rapidly degraded absorbable suture materials 3. closure of the abdomen under tension 4. infection

24. Clinical Questions 13. What are the common causes of incisional hernias?(contd). Ans: 5. Male sex 6. advanced age 7. morbid obesity 8. abdominal disstention 9.cigarette smoking 10.pulmonary disease 11.hypoalbuminemia

25. Clinical Questions 13. What are the goals of treatment of incisional hernias? Ans: -reduce hernial content - repair the fascial defect - prevent recurrence of incisional hernia after the repair

26. Clinical Questions 14. What are the treatment options for incisional hernias?

27. TREATMENT OPTIONS

28. TREATMENT OPTIONS

29. TREATMENT OPTIONS

30. TREATMENT OPTIONS

31. Clinical Questions 15. What home instructions can one give to patients who underwent incisional hernia repairs? Ans: - Avoid straining Avoid lifting heavy objects/ learn the proper mechanics of lifting High fiber diet Quit smoking Maintain a healthy weight

32. THANK YOU

33. References • Nyhus. Hernia. Lippincott Co.1995 • Fitzgibobns, et al open hernia repair, Section 5 Chapter 27 ACS Principles and Practice 2003