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.
component separation technique, eTEP and TAR technique (Transversus abdominus release technique). These techniques are indicated in the incisionalhernias beyond 8 cm defect. Incisionalhernias have been reported in upto 20% of patients undergoing laparotomy. Modern rates of incisional hernia range from 2%-11% (Santora, 1993). It is estimated that approximately 100,000 ventral incisional hernia repairs are performed each year in the United States alone. The incidence seems to be lower in smaller incisions so that laparoscopic port site hernias are much less common than hernias following large midline abdominal incisions. The incidence of incisional hernia occurring at the port sites after laparoscopic surgery, lies between 0.02 to 3.6% (Yuen, 1995) and remains unreported, until the development of complications (Lamont, 1988). Approximately 50% of all incisionalhernias develop or present within the first 2 years following surgery, and 74% occur within 3 years (Read, 1989). Multiple risk factors exist for the development of an incisional hernia. Some of these risk factors are under the control of surgeon at the time of initial operation, while many others are patient specific or related to postoperative complications.
Incisional hernia is a protrusion of abdominal viscera through the site of previous operation or traumatic wound of the abdominal wall except hernial site. 1 Even with the recent advances in surgery, anaesthesiology, antibiotics, suture materials, the incidence of incisional hernia has been atleast 10 per cent. Incidence of incisional hernia is next only to inguinal hernia.and may be higher than reported, since most of these are asymptomatic, but quite sometimes this is one incidence where the remedy has turned out to be worst than malady where in a patient who undergoes surgery for a relatively minor surgical problem may end up with a strangulated hernia.
These hernias may occur after large surgeries such as intestinal or vascular (large arteries, and veins) surgery, or after smaller surgeries such as an appendectomy or an even through the small scar of a laparoscopy wound. Surgical correction of Incisionalhernias is usually recommended, as they carry a potential risk of becoming strangulated at the opening in the abdominal wall and having their blood supply cut off. If this happens it becomes a medical and surgical emergency.
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.
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.
Majority of the earlier observational cohort studies showed a clear benefit in laparoscopic abdominal wall her- nia repairs in terms of recurrence rates, less pain, earlier return to work and shortened hospital stay (12-13). A meta analysis of five randomised controlled trail (14) by Sajid et al showed similar postoperative pain and recurrence in both laparoscopic and open groups. The length of hospital stay and complication rates was lower in the laparoscopic group. A recent meta analysis of eight RCT’s (1) has again dem- onstrated no difference between the recurrence rates for lap vs. open incisional hernia repairs. Length of hospital stay, incidence of wound infections and infections requiring mesh removal was smaller in the lap group. Interestingly enough in this review the pooled hernia recurrence rates for open and lap incisional hernia repairs were 3.4 and 3.6% respectively. This is not in keeping with the previously reported rates of up to 32% risk of recurrence after an open incisional hernia repair with a 10 year follow up period (15). The authors on the Forbes review (1) admitted that the low recurrence rates for both the lap and open group in their review might be because of the shorter length of fol- low up, small size of hernias included in the trials and lack of definition of hernia recurrence. Recurrence rates after laparoscopic ventral hernias range from 1-17% (16). This wide variations is not only because of the afore mentioned factors but also due to patient related factors such as co morbidities, BMI, steroid use, and surgeon experience. The recurrence rate in our study is 13%. We realise that our follow up data is not complete; 10 out of 40 patients could not be contacted. However our recurrence rate is n keeping with the other studies in the literature.
When the contents of the massive hernial sac are reduced into the abdominal cavity, the increase in intra- abdominal pressure causes venous hypertension in the lower extremities, presumably with an increase in incidence of deep vein thrombosis in lower extremities. This can be prevented by low doses of anticoagulant therapy continued until the patient can walk and is ready for discharge. Active limb movements in early postoperative period is also helpful.
Abdominal wall hernias occur when tissue structure and function are lost at the load-bearing muscle, tendon, and fascial layer. The fundamental biologic mechanisms are primary fascial pathology or surgical wound failure. In both cases, cellular and extra cellular molecular matrix defects occur. Acquired collagen defects were ascribed to cigarette smoking and nutritional deficiencies. Secondary fascial pathology occurs following acute laparotomy wound failure. This is in large part due to the replacement of fascial planes with scar tissue. The incidence of recurrent incisional hernia increases with each attempt at repair. Straining at coughing and weight lifting, can induce secondary changes in tissue fibroblast function within load-bearing tissues of recurrent incisionalhernias.
Major abdominal surgery developed rapidly during the latter part of the last century and with it rose the incidence of post operative hernias. For more than 100 years, attempts have been made to develop successful methods for repairing them, but most attempts were followed by a high incidence of complications and a high recurrence rate. Many of the methods such as those described by Judd in 1912, Gibson in 1920 and Nuttall in 1937 were major operations involving a great deal of dissection of the tissues and complicated re arrangements of the abdominal muscles and aponeuroses. These operations were frequently sutured under tension so that many inevitably broke down, leaving the patient worse than before.
Obesity has long been recognized as one of the most relevant conditions predisposing to the development of incisional hernia, a very frequent yet late complication of laparotomic surgery, complicating it even more so by hindering further management through the breakdown or loss of fascial closure. Thus making it both a cause & predisposing factor to the recurrence & occurrence of incisionalhernias. Many incisionalhernias are asymptomatic, but if symptoms are present, an incisional hernia may be associated with major morbidity, loss of time from productive employment, and diminished quality of life, not to mention the loss of productivity of the initial surgery itself.
Concrete is a major material used in the construction The municipal solid waste management continues to remain as one of the most neglected areas of urban development in India. In most of the cities in India, more than half of the solid waste generation remains unattended. The problem is likely to aggravate further with the rise in population, changing food habits and people life style due to changes in socioeconomic status etc. this gives rise to insanitary conditions
Mann-Whitney tests for continuous variables (consider- ing whether the normality assumption is rejected by the Kolmogorov-Smirnov test with Lilliefors correction test), and chi-square tests for categorical variables. The pri- mary outcome (incisional hernia) will be analyzed with Kaplan-Meier analysis and a Cox regression analysis, to adjust for any loss to follow up between 30 days and 1 year after surgery. The primary analysis is a covariate adjusted Cox model, which includes the following pre- defined, well-establihed predictors of incisional hernia: abdominal aneurysm aorta (AAA), obesity, diabetes, cor- ticosteroid usage, radiotherapy, COPD, smoking, age, cancer, inguinal hernia, cardiovascular disease and col- lagen disorders.
increase in the workload but it is that power which put a fire in the qualified and dedicated workers and a wonderful improvement in the productivity can be enjoyed. At last but the most important point comes for productivity improvement that is rewards. Compensation is one of the most important topics of discussion in human resource management. Here in the case of productivity pay for performance will firstly work, which means more the work of more the productivity more the rewards or pay will be given to the employees. Second aspect is the compensation package being given to the employees that is the combination of various benefits.
Results: Male to female ratio was (9:1). Cut throat injury was more common in males who came from rural area. Most of them were unemployed and of low socioeconomic group and of low education level. Cut throat injuries were common in Hindu religion followed by Muslims. The most common cause of cut throat injury in our study was homicidal 17 (56.6%) followed by suicidal 9 (30%) and accidental 4 (13.3%). In our study 11 (36.6%) cut throats were superficial and 19 (63.33%) were deep. 19 (63.33) cases sustained grieveous injury with 7 patients were dead. In all the cases (100%) skin, soft tissue and small vessels were severed. The laryngotracheal injury was present in 12 cases. The majority of patients reached the hospital between 6-10 hours. Simple wound closure was done in 17 cases. 30 patients 23 patients had improved in follow up with no complaint of alteration in voice. 12 (40%) patients had stay of around 0–10 days and with only 10 (33.33%).
A prospective observational study was conducted over a period of six months at Obstetrics and gynecology Department of Bharati hospital and Research centre Pune. All pregnant women attending the antenatal clinic were screened for preeclampsia. Data were collected in Pregnancy Hypertension Patient Performa & Patient Medication History Form. The salient features of pro- forma included name, age, obstetrical history, present- ing complaints, blood pressure on antenatal check-up, decreased foetal movements, past medical history , fam- ily history, medication history, laboratory reports etc. Blood pressure readings were measured four hourly and noted in the pregnancy hypertension patient per- forma. Fetal parameters such as gender, birth weight, and survival status (liveborn, or neonatal death) were also noted.
This has led to an increased application of prosthetic mesh for repair in all the complex incisional hernia defined as diameter >6cm size in either axis or multiple defects with defective abdominal musculature and even inmost of the simple incisional hernia. The use of non absorbable mesh may lead to seroma, fistula and infection in short term and to foreign-body reaction,chronic inflammation, pain, paraesthesia, stiffness and mesh shrinkage as long term complications (11-14) . Meshproperties (material, pore size, filament structure), mesh position (onlay, inlay, sublay, intraperitoneal). use of autodermal tissues and other factors (drainage. antibiotics) influence mesh safety.
hernia followed quickly by tenderness, and signs and symptoms of sepsis. Here cough impulse will be absent. Incarceration and strangulation of a groin hernia may present as a bowel obstruction when the tight hernia defect constricts the lumen of the viscus. All patients with symptom of bowel obstruction needs a detailed physical examination of the groin region for inguinal and femoral hernias. If there is no bowel in the hernia sac, an incarcerated groin hernia may alternatively present as a hard, painful mass that is tender to palpation. The physical exam differs between an incarcerated and a strangulated hernia. The incarcerated hernia may be mildly tender due to venous congestion from the tight defect. The strangulated hernia will be tender and warm and may have surrounding skin erythema secondary to the inflammatory reaction from the ischemic bowel. The patient with the strangulated hernia may have a fever, hypotension from early bacteremia and leukocytosis. The incarcerated hernia requires operation on an urgent basis within 6 to 12 hours of presentation. If the operation is delayed for any reason, serial physical exams are mandated to follow any change in the hernia site indicating the onset of tissue loss. The strangulated hernia clearly requires emergency operation immediately following diagnosis.