APPENDIX I
6. BRIEF REUSME OF THE INTENDED WORK:
APPENDIX – IA
6.1 NEED FOR THE STUDY
Hernia is a protrusion of a viscus or part of a viscus through a normal and abnormal opening in the walls of its containing cavity*1.External abdominal wall hernias occur only at sites where aponeurosis and fascia are not covered by striated muscles*2Ventral hernia is protrusion of an abdominal viscis or part of viscus through the anterior abdominal wall occuring at any site other than groin.Hernias of the anterior abdominal wall are the most common forms,most frequent being Inguinal,Femoral, Umbilical accounting for 75%,of cases, rare forms constitute1.5% excluding Incisional hernias.*1
Incisional Hernias are unique in that they are the only abdominal wall hernias that are considered to be iatrogenic. They are common after vertical lower midline incision used for hystrectomy. Incisional hernia may occur infrequently after appendicectomy, closure of colostomy, subcostal incision for cholesystectomy or spleenectomy, suture holes or drain wounds. Laparoscopic port wounds, at lumbar incision following nephrectomy or other urologic procedures, lumbar sympathectomy and parastomal hernias.
Surgery is the definitive treatment for hernias,though strategy of watchful waiting is safe for elderly patients with asymptomatic or minimally symptomatic hernias.
Hence the need for study.
To know
1.The occurence of ventral hernias with special relation to age, sex and occupation of the patient.
2.Various modes of presentation of ventral hernias.
3.Risk factors and pre disposing factors for the development of ventral hernias.
4.Various treatment options currently available and the changing trend
5.Post operative complications of hernia repair and their management.
APPENDIX I
6.2 REVIEW OF LITERATURE
Hernias are common problem, it is estimated that 5% of the population will develop an abdominal wall hernia but the prevalence may be even higher*2. As rightly said by great Surgeon Sir Astely Paston Copper(1804) No desease of the human body belonging to the province of the Surgeon requires in its treatment a better combination of accurate anotomical knowledge with surgical skill than Hernia in all it’s varieties’ *1
Therefore it is essential for a surgeon to know all about hernia.
In the begining when there is a tendency to herniate, patients complains of dragging and aching type of pain which gets worse as day progresses. Pain may appear long before the lump is noticed. This continues as long as hernia is progressive but ceases when it is fully formed, pain is severe and generalized all over the abdomen due to drag on mesentry or omentum and in case of strangulation. If the hernia is obstructing the lumen of bowel, cardinal symptoms of intestinal obstruction like colicky pain, vomiting, distention of abdomen, absolute constipation may appear. History suggestive of chronic bronchitis, BPH, mass per abdomen may be present. Causes of decreased muscular tone like repeated births, operations may be present.*3
Diligent physical examination in both standing and supine position is essential for evaluation of hernias. Imaging modalities may play a greater role in diagnosis of more unusual hernias *2.
Ventral hernias can be classified as
a) Congenital- Omphalocele
Gastroschisis
Umbilical hernia
b) Acquired- Midline- diastasis recti
epigastric
umbilical(adult)
paraumbilical
Median- supravesical- anterior, posterior, lateral
Paramedian- spigelian
Interparietal- preperitoneal, interstitial, superficial
Incisional
Trumatic
Hernias if not treated may go for complications like
6.Irreducibility
7.Obstruction
8.incarceration
9.strangulation
10.inflammation*4.
Hence the operation is the treatment of choice even in patients with bad cough as they are the very people in danger of developing strangulated hernia*1.
No treatment is offered in patients
1.with severe general ill-health
2.short life expectancy
3.those who refuse surgery*5
.
In adults local, epidural, spinal as well as general aneasthisia can be used for repair of hernias*1. The use of local anaesthesia results in
1.increased day case rates
2. lesser post operative analgesics requirement
3.fewer micturition problems *6
Several synthetic and biologically derived materials have been used to repair abdominal wall hernias. The characteristics of ideal body wall repair material include
- Adequate strength for intended surgical application
- Surgeon friendly handling characteristics
- Non carcinogenic
- Must also fail to elicit an acute hypersensitivity reaction or rejection or to induce a chronic non-inflamatory or foreign body reaction i.e Biocompatibility
- capable of sterilization
Acellular porcine derived cross linked collagen implant is one such tried recently*7
Operative methods for repair of incisional hernias
Three basic methods are
1.simple apposition
2.complex apposition
3.plasitc fibre mesh or net closures*1
Many of the complex apposition methods have become obsalete and mesh repair is the repair of choice irrespective of the type of hernia.
Operative methods of epigastric hernia.
1.Simple suture closure
2.reconstruction of linea alba by
1.modified shoe lace technique
2.vertical mask closure
3.double breasted method
3.Prosthetic buttressing repair
Treatment for diveriction of recti is abdominal corset.
Operative treatment for spigelian hernia is hernioplasty.
Laparoscopic repair of groin and other abdominal wall hernias has the advantages of fewer wound complications , less post operative pain, and for incisional Hernias, short in-patient stay compared to open repair. Recurrent hernias after open repair are repaired laparoscopically without the need to dissect through the scar tissue reducing the risk of inadvartent injury to nerves and vessels. Various method/approaches includes
1.Total extra peritoneal approach( TEP)
2.Transabdominal pre peritonial approach(TAPP)
3.Intraperitoneal onlay mesh repair*8 *9
Totally extraperitoneal repair (TEP) was developed out of concerns for possible complications related to intra abdominal access required for TAPP.this method allows for access to preperitoneal space and avoids the need for a peritoneal incision . In an extraperitoneal laparoscopic repair , access to preperitoneal space is achived with a dissecting ballon ,a laparoscope , or ablunt dissection /corbon dioxide dissection while visualisng the dissection from peritoneal cavity. A mesh prosthesis is inserted into the preperitoneal space .
As in the TAPP repair technical variations exists in mesh fixation methods (tacks, no tacks or fibrin glue ) and mesh configurations (wrapped around cord or 3-D )Unlike in TAPP closure of a peritoneal flap is not necessary in TEP.(12)
Though complications are rare following hernia repair, commonly encountered are
1.Recurrence and readminssions
2.Infections
3.Haemotomas/seromas
4.Bladder injury/ urinary retention
5.testicular injury/ post operative hydrocele
6.Vasdeferense injury
7.enterotomy*10
8.neuralgia/Chronic groin pain and pain related sexual disfunction.* 11
APPENDIX - IC
6.3AIMS AND OBJECTIVES
the main objectives aims of this prospective study is
1.To study the modes of presentations, risk factors & predisposing factors and complications of ventral hernias
2.To study various surgical options currently available to treat ventral hernias and the changing trends.
APPENDIX II
7. MATERIALS AND METHODS
APPENDIX – IIA
7.1 SOURCE OF DATA
The material for the present study is proposed to be collected from patients admitted with Ventral hernias at Sri Adichunchanagiri Hospital& Research Centre ( SAH&RC) B.G Nagara attached to Adichunchanagiri Institute of Medical Sciences B.G.Nagara from June 2008 to January 2010.(minimum of 30)
APPENDIX - IIB
7.2. METHOD OF COLLECTION OF DATA
1.Detailed history taking
2.thorough physical examination
3.relevent investigations (APPENDIX –IIC)
4.Assesment of patients following treatment at regular intrevals in comparision to her/his pretreatment with regards to symptoms.
INCLUSION CRITERIA
1Symptomatic patients with swelling with or without pain
2.Complications of hernias as irreducibility, obstruction, incarceration, strangulation, inflammation
3.recurrent hernias
SPECIFIC CRITERIA
Only Ventral hernias viz,1.epigastric hernias
2.umbilical hernias
3.para umbilical hernias
4.gastroschisis
5.omphalocele
6.divarication of recti
7.spigelian hernias
8.incisional hernias/post traumatic hernias are included.
EXCLUSION CRITERIA
1.all those patients treated on OPD basis
2 Patients with other hernias like internal hernias,lumbar, pelvic,obturator,sciatic,perineal hernias are not included.
APPENDIX –IIC
7.3 Does the study requires any investigations or interventions to be conducted on patients or other animals, if so describe breifly- Yes
INVESTIGATIONS
Routine investigations like
1.Hb%
2.TC &DC
3.ESR
4.BT &CT
5.Urine routine ;albumin,sugar,microscopy.
6.RBS (if diabetic then FBS & PPBS)
7.Blood urea
8.serum creatine
9.Chest X-Ray
10.ECG (Echocardiography If needed)
Special investigations like,1.USG –Abdomen&scrotum in males
Abdomen &pelvis in females
When required 2.Barium study
3.plain X-Ray abdomen
4.UpperG.I.Endoscopy If needed 5’CT
6.Diagnostic laparoscopy
7.Doppler
TREATMENT
Depending upon the merits of the disease and affordablity of patients
1.conservative ie NO treatment or abdominal belt/corset
2.operative treatment-1.herniotomy
2.herniorrhaphy
3.hernioplasty(mesh repair)
4.if available laparoscopic repair like TEP,TAPP,IPOM.
APPENDIX III
8. LIST OF REFERENCES
1.Andrew N Kingsworth Giorgy Giorgobiani and David H Bannett, Hernias umbilicus and abdominal wall, Pg no. 968-990, Bailey & Love’s Short Practice of surgery 25th Edition, Hodder Arnold 2008.
- Marc A Malngoni MD and Michel J Rosen MD, Herias, Pgno. 1155-1179 section 10 Sabiston text boob of Surgery, The Biological basis of modern Surgericcal practice Vol 2 18th Edn Saunders Elsevier.
- Soman Das, Examination of a case of Hernia, Pg no. 428-435 A manual on Clinical Surgery, including special investigation and differential diagnosis, Dr S Das.
- Dr. Rajgopal Shenoy, Hernias Pg no. 551-573, Manipal Manual of Surgery 2nd Edn. CBS Publishers and distributers.
- Dr. Soman Das, Hernias Pg no. 1051-1082, A Concise Text book of Surgery, Publisher Dr. S Das
- P Sanjay, A WoodWard, Inguinal Hernia repair ; Local or general anaesthesia ? Annals of the Royal college of Surgeons of English 2007 89; 497-503
- T M Hammond, J Chin Eleong, H Navsaria, N S Williams, Human invivo cellular response to a cross linked acellular collagen implant, British journal of Surgery 2008, 95; 438-446
- DFL Watkin, GSM Robertson, Hernias and abdominal wall; pg no 75-94 JM Wellwood, MG TuttonHernail, Laparoscopic repair of groin and other abdominal wall Hernias, Pg no 95-106, General Surgical Operations by RM Kirk 5th Edn Churchil Livingstone, Elsevier
- Margret Farquharson and Brenden Moran, Surgery of the Groin and External Geniatalia, pg no. 458-483, Furcorsons Text book of Operative General Surgery 9th Ed. Harder Arnold
- Patric J David, David C Brooks, Hernais, pg no. 103- 140 section 2, Maingot’s Abdominal Operations, 11th Edn Mcgraw Hills
- H Kehlet, Chronic Pain after Groin Hernia repair, British Journal of Surgery 2008 95; 135-136
- Jon Gould,MD Laparoscopic versus open hernia repair, Advances and Controversies in Minimally Invasive Surgery .Surgical clinics of North America.october 2008, volume 88, number 5.
13.M.Miserez & F.Penninckx , Journal Surgical endoscopy, publisher Springer Newyork,issue volume 16, no 8/ Aug 2002.