Welcome to the January issue of The Surgeons’ Lounge and a Happy New Year to you all! I hope all of our readers had a safe and happy holiday season. I am excited about our guest experts for 2014, who expect to be challenged!
We start the 2014 lineup with a special issue on hernia repair. We are honored to have Emanuele Lo Menzo, MD, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, as our guest expert. Dr. Lo Menzo discusses the case of a patient who is morbidly obese with complaints of worsening sharp abdominal pain and a history of multiple hernias.
Also, take the first challenge of the year, submitted by Shadi Al-Bahri, MD, and David V. Nasrallah, MD, FACS, Department of Surgery, Union Memorial Hospital, Baltimore.
We look forward to another wonderful year and our readers’ correspondence and feedback.
Samuel Szomstein, MD, FACS
Editor, The Surgeons’ Lounge
Dr. Szomstein is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.
From Jorge Huaco, MD,
Swedish Medical Center, Seattle, Washington
A 51-year-old morbidly obese man (body mass index [BMI], 39.1 kg/m2) was referred to our general surgery clinic with complaints of worsening sharp abdominal pain that was localized to his surgical scars. He believed that his previously repaired ventral and umbilical hernias were causing pain due to recurrence.
The patient had undergone multiple abdominal hernia repairs, the first of which was approximately eight years before for what seemed to be a ventral hernia with significant diastasis recti. The patient reported that this had been repaired using an open approach with mesh, due to increased abdominal pain and cosmetic concerns. The patient did well until 2011, when the hernia recurred, requiring another repair (elective open umbilical and ventral hernia repair with prosthetic mesh). His postoperative course was complicated by an abdominal mesh infection with methicillin-resistant Staphylococcus aureus, that required mesh explantation and a new hernia repair with a biologic prosthesis. He subsequently developed small bowel obstruction secondary to adhesions that required open partial small bowel resection with primary anastomosis.
The patient presented to our clinic with complaints of nausea, vomiting and abdominal pain. The nausea and vomiting started in January 2012, a few months after the small bowel resection. It was noted that he was not able to tolerate a regular diet after surgery for an extended period of time. His physician prescribed metoclopramide without effect, and the nausea occurred three to four times weekly with vomiting at least once or twice per week. Eating sometimes exacerbated the nausea and vomiting. He also complained of intermittent bloating and abdominal distention.
The patient’s past medical history is significant for diabetes mellitus with complications such as peripheral neuropathy, well-controlled hypertension, hyperlipidemia, chronic back pain requiring intermittent nonsteroidal anti-inflammatory drugs, and urolithiasis. On physical examination, he had a soft, large mid-abdominal defect, with partial loss of domain. He had some discomfort but no tenderness and no peritoneal signs.
The patient had several imaging studies, including a computed tomography (CT) enterography that showed a wide-mouth ventral hernia with no evidence of bowel obstruction. A repeat nuclear scan was reported as normal gastric emptying of the solid meal (Figures 1-3).
After several visits to the emergency department because of abdominal pain and feeding intolerance, he was finally admitted to the hospital for rehydration and reconsideration of earlier ventral hernia repair. Aside from the abdominal pain, the patient explained that his functional status had been declining due to the hernia, and that he was unable to perform basic activities of daily living (i.e., tying his shoelaces) and to work. Consequently, he had lost his job.
Question 1. What is the proper management and surgical indications for symptomatic diastasis recti?
Question 2. Is this a true recurrence of a ventral hernia? What should be done?
Question 3. What is the most appropriate approach for a recurrent ventral hernia?
Question 4. Would you consider bariatric surgery prior to definitive ventral hernia repair in this specific patient? How about in obese patients in general?
Diastasis recti is a common problem, especially in multiparous women, but it also can occur in men. Essentially, this is a gradual separation of the rectus abdominis with widening of the anterior rectus sheath. This usually does not cause pain or discomfort but, with straining, an elongated bulge can be seen from below the xiphoid process to the umbilicus. When the diastasis extends to the periumbilical area, it often is associated with a true umbilical hernia. The most common cause of diastasis recti in women is secondary to the abdominal wall stretch from the pregnant uterus. In men, the most common causes of diastasis recti are obesity (causing similar pressure on the muscles), or a history of vigorous straining exercises such as sit-ups or weightlifting.
Physical therapy and core exercises have shown some improvement for the defect. The condition almost never produces complications, and therefore surgical correction is not routinely recommended. However, many patients find the defect unsightly and request treatment.
The presence of a symptomatic ventral or umbilical hernia in addition to the diastasis recti has been advocated as an indication for a definitive surgical repair. Whenever a true hernia is diagnosed, open or laparoscopic repair is warranted. The goal of the procedure should be to medialize the recti in the midline and recreate the linea alba, whenever possible. This repair can be accomplished with an open technique by primary repair with or without a prosthetic mesh for larger defects, or in the presence of risk factors for recurrence. Laparoscopically, the midline can be approximated using intracorporeal sutures or unidirectional braided sutures and reinforcing with prosthetic mesh, when necessary. In laparoscopic cases, it is paramount to open the peritoneum and fully reduce the preperitoneal fat before the hernia repair. Failure to complete this step will result in persistence of the subcutaneous lump, and potentially, the symptoms.
The CT scan shows an onlay mesh in the upper part of the repair and a well-defined layer circumferentially around the viscera. There may be an interruption of this layer in the right lower quadrant. It is difficult to confirm if this was a mesh or a pseudosac from a previous biologic mesh based on imaging studies. The patient’s history and physical examination, as well as the availability of the previous operative report, will help in the decision making. In this specific case, the main indication for revision and reconstruction of the abdominal wall would not be the defect per se (large and unlikely to cause bowel incarceration or strangulation), but the significant loss of functional status of the patient, aggravated by chronic pain issues. The foreign materials from multiple previous repairs and the dense adhesions could be the cause of chronic, debilitating abdominal pain.
Recurrent ventral hernias are frequent occurrences in general surgery practices and have become a problem that few surgeons are eager to deal with, especially in patients with multiple recurrences. Several factors contribute to these recurrences: obesity; collagen abnormalities; immunosuppressive medications; improper surgical repair or use of prosthetic and biologic materials; and postoperative complications, such as seromas and/or infections, among others.
Over the past 30 years, the change from primary repair to the widespread use of prosthetic materials has decreased the recurrence of ventral hernias significantly. Without question, other than for minimal ventral defects, the use of a mesh is always indicated. Selecting the most appropriate material depends on the conditions of the patient and the type of repair.
In my opinion, patients with small recurrences of previous repairs (primary or mesh) would be ideal candidates for a subsequent laparoscopic repair. There are some technical aspects that would improve the outcomes and include avoidance of dead spaces and seromas. (Some surgeons would advocate removal of the sac by a small open incision or laparoscopically.) Also, optimal apposition of a double-sided mesh (to avoid bowel adhesions) with transfascial sutures and tacks, maintaining a flat lie of the mesh, would help decrease the chances of further recurrence.
For larger defects, especially when abdominal wall function is one of the primary objectives of the repair, abdominal wall reconstruction should be considered. This includes medialization of the musculoaponeurotic complex by one of the types of component separation described. The repair should be reinforced with either synthetic or biologic mesh, preferably in the retrorectus space, which will keep the integrity of the peritoneal lining and maintain the mesh in a constrained space. An important aspect, especially in obese patients, is avoidance of large dead space and seroma formation; this could be achieved by excision of redundant skin and subcutaneous tissue (panniculectomy), broad drainage of subcutaneous and subfascial space, and possibly the use of incisional negative pressure systems.
Obesity is one of the leading causes of hernia recurrence. In this patient population, the presence of increased abdominal pressure, a chronic inflammatory state and frequent association with comorbidities such as diabetes, could very likely contribute to hernia recurrence. Also, obese patients are more prone to developing surgical site infections.
In the management of a morbidly obese patient with ventral hernia, especially if recurrent, weight loss should be the primary goal before hernia repair options are discussed. Given that diet and exercise alone have very limited results, discussion about bariatric surgery should be started. If patients are not interested in bariatric surgery, then as part of the surgical consent process, we must initiate a clear and thorough discussion about higher recurrence rates and surgical wound events, including surgical site infection. If bariatric surgery is an option, this should be carried out first and the hernia should be left undisturbed, as much as possible.
In the case presented here, given that the patient had multiple hernia repairs and previous bowel surgery with extensive adhesions, the best bariatric surgery option would be a sleeve gastrectomy. Definitive abdominal wall reconstruction can be performed at the time of maximum weight loss (12-15 months after surgery), and should be combined with a panniculectomy.
Submitted by Shadi Al-Bahri, MD, and David V. Nasrallah, MD, FACS,
Department of Surgery, Union Memorial Hospital, Baltimore, Maryland
A 27-year-old man presented to the emergency department with a week-long history of abdominal pain, readmitted with worsening symptoms, associated with fever and loss of appetite. His medical history was not significant except for recent travel to Mexico and Canada, and a questionable diagnosis of Crohn’s disease. An abdominal CT scan performed a week before this presentation showed thickened small bowel loops in the right lower quadrant consistent with Crohn’s disease. His repeat CT scan on this presentation (Figure), however, revealed pneumoperitoneum consistent with a perforated viscus as well as a more pronounced circumferential small bowel wall thickening of the distal ileum. At that time, his white blood cell count was elevated at 12,400/mL, and his abdominal examination revealed a rigid abdomen with rebound tenderness, localized to the midline below the umbilicus. The above findings were concerning for perforated small bowel, and therefore the patient was taken emergently to the operating room.
What is the diagnosis?
A. Perforated appendicitis
B. Crohn’s disease
C. Foreign body
D. Carcinoid tumor