ABDOMINAL WALL Flashcards
(14 cards)
Management of small and asymptomatic ventral hernia?
Observe
Management of large or symptomatic ventra hernia?
- BMI < 30?
- BMI 30-40?
- BMI > 40?
- BMI <30: Elective repair
- BMI 30-40: Elective or staged repair
- BMI > 40: Staged repair (start w/ weight loss and possible bariatric surgery)
Approach for repair of grynfeltt hernia?
Through superior lumbar triangle
Approach for repair of petis hernia?
Through inferior lumbar triangle
Management of uncomplicated hernia with ascites?
Aggressive medical management
- Sodium restriction
- Diuresis
- Paracentesis
- Nutritional optimization
Options for repair of uncomplicated hernia with ascites if initial management fails?
- intermitent paracentesis
- TIPS
Indications for emergent repair of hernia with ascites?
- Incarceration or strangulation
- Skin rupture
- Skin changes suggesting impending rupture
Management of hernia mesh infection?
- Superficial?
- Deep?
- Superficial: abx x10-14 days and consider surgical drainage or perc aspiration
- Deep: Debridement and mesh explantation, may consider nonop trial with perc drainage if there are no systemic signs
PROCEDURE STEPS: Open inguinal hernia repair
- Skin incision 6-8 cm parallel to inguinal ligament
- Expose and incise external oblique aponeurosis
- Encircle spermatic cord with Penrose drain
- Reduce hernia
- Repair
- Lichetenstein: affix mesh to pubic tubercle, suture to shelving edge inferiorly, suture to internal oblique superiorly
- Bassini: Longitudinally divide posterior walla / transversalis fascia, approximate conjoint tendon to inguinal ligament
- McVay: Longitudinally divide posterior wall / transversalis fascia, approximate conjoint tendon to Cooper’s ligament, include transition stitch to inguinal ligament, create relaxing incision to anterior rectus sheath
PROCEDURE STEPS: TAPP repair
- Port placement: 10 mm umbilicus, 5 mm x2, 5-6 cm lateral to umbilicus on each side
- Peritoneum opened from ASIS to medial umbilical fold
- Dissect myopectineal orifice
- Reduce hernia sac
- Place large mesh over MPO, consider fixation
- Close peritoneum
PROCEDURE STEPS: TEPP repair
- INFRAUMBILICAL INCISION *
- 1-2 cm infraumbilical incision
- Dissect anterior fascia
- Expose rectus muscle
- Incise anterior rectus sheath just off of midline
- Split rectus to access posterior sheath
- PREPERITONEAL DISSECTION *
- Balloon dissect to open preperitoneal space
- Remove balloon and insufflate preperitoneal space
- Insert camera and then 5 mm ports x2 inferiorly along midline
- Dissect MPO
- Reduce hernia sac
- Place large mesh over MPO, consider fixation
- Close any inadvertent peritoneal tears
PROCEDURE STEPS: Rives-Stoppa-Wantz (Retrorectus) hernia repair
- Midline incision
- Excise hernia sac
- Incise posterior rectus sheath close to junction of anterior rectus sheath (without sacrificing anterior sheath)
- Separate posterior rectus sheath away from rectus muscle to create retrorectus space
- Close posterior rectus sheath
- Place large mesh into retrorectus space
- Close anterior rectus sheath
- Close skin
- Drains: Consider retrorectus drain over mesh, and a subcutaneous drain in fat plane
PROCEDURE STEPS: Anterior component separation
- Create subcutaneous flaps out to the anterior axillary line
- Incise external oblique aponeurosis 2 cm lateral to the semilunar line
- Dissect the plane laterally between the external and internal olbiques
- Reconstruction:
- Consider mesh placement (onlay/subQ, retrorectus, or preperitoneal)
- Reapproximate anterior rectus sheath to midline
- Consider drain placement (debated) - Close skin
PROCEDURE STEPS: Component separation with transversus abdominus release (TAR)
- Incise dorsal aspect of posterior rectus sheath 1 cm from medial edge of rectus, then enter retrorectus space and dissect laterally to semilunar line
- Incise ventral aspect of posterior rectus sheath at lateral-most edge
- Incsise transversus muscle along its length at the medial aspect to enter the preperitoneal space (taking care not to penetrate transversalis fascia / peritoneum)
- Dissect laterally between transversalis abdominus (anterior) and transversalis fascia / peritoneum (posterior)
- Reconstruction:
- Reapproximate posterior rectus sheath to midline
- Place large retrorectus mesh
- Reapproximate anterior rectus sheath to midline
- Consider drain (debated) - Close skin
