This is to certify that this dissertation titled “COMPARATIVE STUDY OF POSTERIOR COMPONENT SEPARATION TECHNIQUE – TRANSVERSE ABDOMINIS RELEASE IN LARGE INCISIONALHERNIAS WITH ONLAY MESH REPAIR” of the candidate Dr. M. SURESH KUMAR with registration number 221611124 for the award of M.S degree in the branch of GENERAL SURGERY. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file containing from introduction to conclusion pages and result shows 15 percentage of plagiarism in the dissertation.
These defects can be categorized as spontaneous or acquired or on the abdominal wall. Epigastric hernias occur from xiphoid process to umbilicus, umbilical hernias occur at umbilicus, and hypogastric hernias are rare spontaneous hernias that occur below the umbilicus in the Acquired hernias typically occur after surgical incisions and are therefore termed incisional hernias.A postoperative ventral abdominal wall hernia, more commonly termed incisional hernia, is the result of a failure of fascial tissues to heal and close following laparotomy. Such hernias n occur after any type of abdominal wall incision, although the highest incidence is seen with midline and transverse Postoperative ventral hernias following paramedian, subcostal, McBurney, Pfannensteil and also been described in literature. Laparoscopic port sites may also develop hernia defects in the It is agreed that incisionalhernias that develop between linea alba and linea semilunaris are laparoscopic suited hernias and the ones that develop outside the linea semilunaris towards flanks are laparoscopic unsuited hernias. The hernias that develop in the lateral part of the abdominal wall in the flanks need different techniques which include anterior component separation technique, posterior INTERNATIONAL JOURNAL
I, Dr. PONCHIDAMBARAM.M solemnly declare that the dissertation titled “A CASE STUDY ON COMPARISON OF RETROMUSCULAR PREFASCIAL PLACEMENT OF MESH VERSUS ONLAY MESH PLACEMENT IN REPAIR OF INCISIONALHERNIAS” has been prepared by me at Department of Surgery, Madurai Medical College, Madurai, in partial fulfillment of the regulation for the award of M.S. (GENERAL SURGERY) degree examination of The Tamil Nadu Dr. M.G.R. Medical University, Chennai to be held in September 2006.
Methods/design: This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisionalhernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome.
If we carefully review the post operative patients by simply asking them to raise their legs we can see a bulge over the healed abdominal wound. Patients goes happily with gay but unfortunately notices an ugly, unsightly swelling on the abdomen over the operated area in a near future. Since most of the incisionalhernias are symptomless to the patient fails to recognize it or even after recognizing it he fails to return to the same doctor. It is difficult to estimate the real incidence of post operative hernias. So actual incidence will be much more than that is recorded.
In rural areas of Burkina Faso, incisionalhernias occur in young patients. Peri- tonitis and occlusions are the main indications of first surgery. The vertical mid- line incisions are involved in more than half of the cases. Prostheses are less ac- cessible financially. As such, the treatment mainly involves open suture repair with a high rate of recurrence. The technique of Lázaro Da Silva could be an al- ternative choice.
Incisionalhernias are a prevalent problem in abdominal surgery and occur in 11% of patients who undergo laparotomy. Primary suture clo- sure of incisionalhernias results in a 31%-58% chance of recurrence. The addition of a pros- thetic mesh implant decreases recurrence rates to 8%-10%. Popularized in Europe by Rives and Stoppa, the sublay technique has proven to be very effective, with low recurrence rates (0%-23%) and minimal complications. The pur- pose of the study was to evaluate the experi- ence of a single surgeon at a large tertiary care center performing a modified Rives-Stoppa re- pair for abdominal incisionalhernias. To do this, the records of all patients undergoing a modi- fied Rives-Stoppa incisional hernia repair be- tween January 2000 and August 2003 were ret- rospectively reviewed. Outpatient clinic notes, discharge summaries, operative reports, and laboratory data were reviewed for patient demographics, surgical data and postoperative complications. Univariate analysis was per- formed in order to identify predictors for recur- rence. During the study period, 83 patients un- derwent a modified Rives-Stoppa incisional hernia repair. Nineteen patients were excluded due to incomplete medical records. No patients required postoperative exploration for an in- tra-abdominal catastrophe. Twenty-five percent (n=16) of patients had a complication as a result of the hernia repair. Only two patients (3.1%) developed recurrent incisionalhernias. History of diabetes (p=0.007) and benign prostatic hy- perplasia (p=0.000) were the only significant predictors for recurrence. The results presented here confirm that the modified Rives-Stoppa retromuscular repair is an effective method for the repair of incisionalhernias. The complica-
Ventral hernias are often noted by the patient as an abdominal bulge. They can be exacerbated by any action that rises intraabdominal pressure such as coughing, lifting weights, valsalva manoeuvre or by head or leg rising. Rest or reduction of the incarcerated hernia may offer temporary relief. Smaller hernias are often assymptamatic or produce intermittent dragging pain. Discomfort of the ventral bulge is the most common initial symptom. But bowel obstruction can also be the first symptom that forces the patient to seek medical attention. Incarceration and strangulation are more common if the hernia neck defect is small. Skin may undergo pressure ischaemic necrosis.
The process of wound healing collagen formation and maturation the laying down of the collagen fibres in parallel lines according to the lines of stress, and the healed wound gaining its maximum strength takes about 1 year. Approximately 80 % of the final wound strength is reached after 6 months. It follows therefore that the wound must be supported for at least this time. The sutures are entirely responsible for the integrity of the wound for the first 6 months, so any material that does not survive and maintain most of its strength for this time is not suitable for wound closure. Corman and colleagues at the Lahay clinic evaluated three suture materials, nylon, polypropylene and vicryl in a study of 161 abdominal wall closures following bowel operations. After one year incisionalhernias occurred in six patients, but none occurred in the vicryl group and they concluded that vicryl was the most appropriate suture material for abdominal closure following bowel operations. Of the remaining materials available for suturing are stainless steel, nylon, silk, polyester and polypropylene which are nonabsorbable.
This study is based on the analysis of the cases of incisional hernia seen at the Coimbatore College Hospital during 2007 – 2009. The previous operations in these cases were performed at various hospitals in and around Coimbatore, including ours. In many of the cases it was difficult to determine the postoperative courses of events from the history alone. Surprisingly many patients would describe the postoperative infections and wound disruption. Unfortunately the follow up observations of a few patients were limited. The age and sex incidence, details of initial operative procedures, complications following initial operations, onset of incisionalhernias, site of incisionalhernias, methods of repair, complications following repair and mortality were studied and discussed in detail.
In Maingot's study of 1129 major laparotomies in which there were 19 burst abdomens and 84 incisionalhernias, it was found that wound herniation was more common at a statistically significant level in the elderly, in men, in the obese, in patient's undergoing bowel surgery, and in patients with incision more than 18 cm. Post operative complication particularly chest infection, abdominal distention and wound infection were the most significant factors associated with herniation and these factors tended to occur in combination. The part played by wound sepsis appeared to be the most important; 48% of the 179 patients who developed a wound infection went on to develop an incisional hernia.
Despite considerable improvements in incisional hernia treatment, infections associated with incisionalhernias remain a difficult problem. The use of innovative mate- rials, such as biological meshes, is thought to be the most suitable treatment, due to their specific composition. The non-human collagen matrix can support tissue regen- eration through neovascularization and fibroblastic cell re- population leading to endogenous collagen formation. The exogenous collagen is then resorbed by collagenases. These biological meshes have two main properties: resist- ance to infection and mechanical resistance, which theor- etically facilitate treatment of the infected incisional hernia . The use of biological meshes has expanded rapidly in recent years, despite a lack of substantial evidence and their high cost. No comparative trial is available at the present time, specifically for infected incisionalhernias (grade 4 on the VHWG grading system). The most significant study was presented as a poster at the American College of Surgeons Clinical Congress in 2010, which included 80 patients in infected and contaminated fields; however, this was an observa- tional, non-comparative study . A randomized, con- trolled trial, sponsored by industry, has been designed, comparing the biological mesh Tutomesh to fascia clos- ure without mesh reinforcement in potentially contami- nated fields (grade 3 on the VHWG grading system), but the results are still unknown. It is therefore important to evaluate biological meshes, using both medical and eco- nomic parameters, for patients most suitable for their use and for whom the cost-benefit balance should be optimal, that is, patients with an incisional ventral hernia with an active infection.
Secondary objectives are the frequencies of early and late onset complications such as burst abdomen, postopera- tive pulmonary complications, wound infections and incisionalhernias after three years postoperatively. Addi- tionally a set of surgical and non-surgical parameters related to the operation will be analysed as secondary objectives such as the frequencies of various complica- tions, the lung function and the postoperative length of hospital stay. A qualitative analysis is included in the study to assess the relevance of the primary endpoint from the patient's and the surgeon's perspective. The following aspects are ranked in a descending order from 1 (= most important) to 9 (= least important): postoperative com- plication, intraoperative complication, length of hospital stay, onset of enteral nutrition, death, postoperative pain, postoperative fatigue, convalescence of the complete physical maximum resilience and cosmetic result . The ranking by the surgeon is done once for each surgeon before the operation. Patients are completing the ranking
These hernias commonly appear as a localised swelling involvinga small portion of the scar but may present as a diffuse bulging of the whole length of the incision. There may be several discrete hernias along the length of the incision and unsuspected defects are often found at operation. Incisionalhernias tend to increase steadily in size with time. The skin overlying large hernias may become thin and atrophic so that peristalsis may be seen in the underlying intestine. Vascular damage to skin may lead to dermatitis. Attacks of partial intestinal obstruction are common as there are usually coexisting internal adhesions. Strangulation is less frequent and most likely to occur when the fibrous defect is small and the sac is large. Most incisionalhernias are broad-necked and carry a low risk of strangulation.
Another promising technique is the Rives-stoppa procedure developed for the repair of incisionalhernias. Prosthetic material is used to close the defect in a so called sublay technique. The prosthesis is placed between the rectus abdominis muscle and posterior sheath. Above the umbilicus, dissection is performed above the posterior rectus fascia and underneath the rectus muscle. Below the umbilicus, the lack of a posterior rectus fascia necessitates dissection in the preperitoneal space. A large piece of polypropylene mesh is placed in the space created, and fixed to muscle layer above with full or partial thickness suture. The recurrence rate with this repair have been stated to be less than 10%.
Between the period of January 2011 to September 2012, 185 cases of ventral hernias treated at TVMCH were studied and followed for a period of 6 to 18 months. Ventral hernias were common surgical problems second only to groin hernias. More than 45% of ventral hernias were Incisional followed by, umbilical, paraumbilical hernias and epigastric hernias.. Most of the Incisionalhernias developed >5yrs of previous surgery. Swelling, pain and complications along with aesthetic concerns are the causes for seeking surgical solution .Most of ventral hernias were uncomplicated at the time of presentation, remaining presented with either obstruction or strangulation necessitating emergency repair. Incidence of Incisionalhernias was more in females with male to female ratio of 6.7:1, while epigastric and umbilical hernias were more common in males with male to female ratio of 4:1 and 1.2:1 respectively. Previous surgery was the single most important cause for ventral (Incisional) hernias. Other etiological factors were multiparity, obesity, anemia, COPD, BPH, diabetes mellitus, alcoholism and smoking. Post operative wound infection was important cause for development of Incisionalhernias.
group. However, this group has engendered such confidence in the method that they now recommend it for routine use in patients more than 60 years of age even with a unilateral hernia, and at the slightest doubt in the patients under 60 years of age, such as those with bilaterial hernias, with a weak abdominal wall, or whose work demands heavy physical labor. They summarized their indications for GPRVS as “those hernias that present a high risk of recurrence such as recurring hernias, bilateral groin hernias, groin hernias associated with low incisionalhernias, simultaneous direct and indirect hernias, large hernias, recurring hernias when poupart’s and/or Cooper’s ligaments are destroyed, and prevascular hernias.” To this list he added those hernias related to collagen diseases such as Ehlers-Dan-es and Marfan syndromes and patients in whom surgery is a risky proposition because of old age, obesity or cirrhosis. This is indeed a long list of patients who make up 30% to 40% of groin hernias in Stoppa’s practice. He reports a series of 2000 cases of GPRVS followed from 1 to 12 years with recurrence rates of 0.56% for primary groin hernias and 1.1% for recurrent groin hernias – a truly remarkable success story when one considers that the “best” cases were operated on by conventional inguinal methods, whereas the “worst” cases were repaired by GPRVS.
Spontaneous rapture (Dehiscence) of Hernia is a well recognized though rare complication, majority occurring in lower abdominal, Inguinal and incisionalHernias. Many develop insidiously while others are associated with episodes of straining (or) coughing. The dehiscence would appear to be a degenerative process, with the relatively avascular and thin hernial sac undergoing progressive stretching, becoming increasingly ischemic and finally giving way. This process is accelerated in some cases by skin ulceration due to Tight corsets (or) to intertrigo and skin infection in pendulous sacs. The main peritoneal cavity is uncontaminated, the Tight neck usually preventing reduction of the contents and contamination.
The sac contains a diverticulum of the peritoneum which is divided into mouth, neck, body and fundus. Usually the neck is well defined but in many incisionalhernias there is no actual neck. The neck is very wide and rarely go for strangulation. The body of the sac varies greatly in size and is not necessarily occupied. In long standing cases the wall of the sac is very much thick. Incisionalhernias may be small but often they are large. They are frequently multilocular and thin walled sac lies between cutaneous scar and the abdominal viscera. Although the sac may represent protrusion of the parietal peritoneum, it is much more likely that is formed by metaplasia membrane. Adhesions between sac and contents are very common.
In case of long standing large incisionalhernias, the viscera are said to have lost the right of domicile because of prolonged period of stay outside the peritoneal cavity, within the hernial sac. The hazards attendant on an operation for such giant hernias centered about the profound changes in ventilator capacity and the reduced venous return to the right side of the heart occasioned by the forcing of a large volume of intestine and omentum back into the abdominal cavity. It was a common experience in the past to operate on such patients, encountering severe cardio respiratory failure within 6-8 hours post operatively.