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26
Parastomal hernia repair options
Repair options
Relocation of ostomy site
Key steps
L. Amodu et al.
Advantages and
disadvantages
Requires a more complex operative
procedure
Creates the possibility of a second
hernia site
Primary repair of
parastomal hernias
Reapproximating fascial defect with sutures Highest recurrence rate
Research
Reference Findings
DeAsis FJ, Lapin B, Gitelis ME, Ujiki
MB.Current state of laparoscopic
parastomal hernia repair: a meta- analysis.
World J Gastroenterol. 2015;21(28):8670–7.
PMID: 26229409
Shah NR, Craft RO, Harold
KL.Parastomal hernia repair. Surg Clin
North Am. 2013;93(5):1185–98
Spigelian hernia
Defect in Spigelian fascia between the rectus muscle and the semilunar line
Denition
Develops at or below the arcuate line (caused by lack of posterior sheath below arcuate line)
Patients often present with localized pain in the area without a bulge because the hernia lies
Presentation
beneath the intact external oblique aponeurosis, i.e. in an intermuscular plane
Hernia dissects posteriorly to the external oblique; a bulge is typically not palpable
The overall postoperative morbidity rate was 1.8% (95%CI:
0.8–3.2), and there was no difference between techniques. The most
common postoperative complication was surgical site infection,
which was seen in 3.8% (95%CI: 2.3–5.7). Eighty-one recurrences
were reported overall for a recurrence rate of 17.4% (95%CI:
9.5–26.9). Recurrence rate was 10.2% (95%CI: 3.9–19.0) for the
modied laparoscopic Sugarbaker approach, whereas the recurrence
rate was 27.9% (95%CI: 12.3–46.9) for the keyhole approach
1 Abdomen andHernia
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Spigelian hernia
Difcult to diagnose on physical examination alone. CT or ultrasonography may help the
clinician make a diagnosis
CT imaging can conrm the diagnosis. However, imaging is not 100% sensitive
Diagnosis can sometimes be made only at operative exploration
Diagnosis
27
Management
Axial abdominal CT image with
oral and IV contrast
demonstrates a right-sided
spigelian hernia
Often associated with bowel incarceration and should be repaired when diagnosed
The best outcome in terms of reducing recurrence involves placement of a permanent prosthetic
mesh
Mesh reinforcement can be performed as an onlay, sublay, or underlay repair. In general, sublay
or underlay mesh placement has been associated with lowest recurrence rates
Axial abdominal CT image with
oral and IV contrast
demonstrates a left-sided
spigelian hernia containing
sigmoid colon and adjacent
inammatory changes (arrows),
consistent with incarceration
Axial chest CTA image
demonstrates a right-sided
fat and bowel-containing
spigelian hernia (arrow)
28
Obturator hernia
Anatomy
L. Amodu et al.
Defect through the obturator membrane (between the pubic bone and ischium)
The obturator nerve and vessels may be compressed by an obturator hernia
The obturator canal is formed by the union of the pubic bone and ischium
This canal is covered by a membrane pierced at the medial and superior border by the obturator
nerve and vessels
Greater sciatic
foramen
Obturator
canal
Obturator
membrane
Ischial tuberosity
True pelvis
Ischial spine
Coccyx
Lesser sciatic
foramen
Obturator hernias are rare, but occur more commonly in women, particularly the elderly
Patients will present with pain or paresthesia in the medial thigh
Presentation
Given the small space, obstruction is common
Howship-Romberg sign: Pain radiating down the medial thigh that is relieved by thigh exion
Diagnosis When a clinical diagnosis is uncertain, CT scan can be used for conrmation
A posterior approach, open or laparoscopic, is preferred
After reduction of the hernia sac and contents, any preperitoneal fat within the obturator canal
is reduced
Management
The obturator foramen is repaired with prosthetic mesh, with care taken to avoid injury to the
obturator nerve and vessels
Patients with compromised bowel usually require laparotomy
Lumbar hernia
May be congenital or acquired (trauma or surgery)
Characteristics
Presentation
Superior (Grynfeltt–Lesshaft) lumbar triangle: 12th rib, paraspinal muscles, internal oblique
muscle
Inferior (Petit) lumbar triangle: Iliac crest, latissimus dorsi, external oblique muscle
This type is often asymptomatic
If it is symptomatic, back pain is a common complaint
Diagnosis When a clinical diagnosis is uncertain, CT scan can be used for conrmation
Management Repair with mesh (open or laparoscopic)
1 Abdomen andHernia
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Rectus Sheath Hematoma
Rectus sheath hematoma
Superior epigastric artery is the terminal branch of the internal thoracic artery
Anatomy
Inferior epigastric artery originates from the external iliac artery
Risk factors Female, elderly, taking anticoagulants, history of COPD, or asthma
Presentation Most common presenting symptoms are: Abdominal pain and palpable abdominal wall mass
Fothergill sign: A palpable abdominal mass that does not cross the midline or change with
contraction of rectus muscle
Clinical signs
Carnett sign: When the point of maximal tenderness on the abdominal wall does not change
when the patient moves from the supine position to the sitting position
Best imaging modality: CT of the abdomen
29
Diagnosis
Management
Hematoma appears as a spindle-shaped mass posterior to rectus abdominis muscle
The density of uid depends on chronicity and use of intravenous contrast
Most appropriate initial intervention is angiographic embolization
If bleeding persists➔surgical intervention may be required
Hematoma evacuation and ligation of bleeding vessels
Ligation of either the superior or inferior epigastric vessels is well tolerated due to collateral
ow from the other epigastric vessel on the same and contralateral side
Classication of rectus sheath hematoma and management
Classication
Type I
Features CT ndings
• Conned within
rectus muscle
• Does not cross
midline or
dissect fascial
planes
Management
Bedrest, analgesia,
compression of the
hematoma, and
reversal of
anticoagulation
when appropriate
Axial abdominal CT image with oral and IV
contrast demonstrates a left-sided hematoma
conned to the rectus sheath (arrow), consistent
with a type I rectus sheath hematoma
30
Classication of rectus sheath hematoma and management
L. Amodu et al.
Classication
Type II
Type III
Features CT ndings
• Conned within
rectus muscle
• Dissect along the
transversalis
fascial plane or
cross the midline
Axial abdominal CT image with oral and IV
contrast demonstrates a right-sided rectus sheath
hematoma that crosses midline (arrow), consistent
with a type II rectus sheath hematoma
• Below the
arcuate line
• Hemoperitoneum
and/or blood
within the
prevesical space
of Retzius
Management
Stable: Same as
type
I+hospitalization
Unstable:
• Angiography
with arterial
embolization is
often the
rst-line
intervention
• Ligation of either
the superior or
inferior
epigastric vessel
Sagittal abdominal CT image with IV contrast
demonstrates a large left-sided rectus sheath
hematoma (arrows) with extension into the
abdominal cavity (arrowhead), consistent with a
type III rectus sheath hematoma
1 Abdomen andHernia
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Peritoneal Dialysis Catheters
Peritoneal dialysis catheter
31
Ideal candidate for PD
catheter
Contraindication
Timing Insertion 2weeks prior to initiation to prevent leaks
Key steps
Patient with residual renal function
Minimal abdominal surgery, no abdominal wall hernias, non-obese
Patients able to perform the exchanges
Lack of a peritoneal membrane
Prior abdominal surgery, hernias, ostomies, and adhesions are not contraindications,
although they may cause problems with lling and solute clearance
Catheter is passed on a stylet and positioned in the pelvis
Deep cuff is anchored in place above the peritoneum
A subcutaneous tunnel is created for the supercial cuff
Catheter is ushed with heparinized saline
With open approach: Stylet is placed in catheter and directed to the pelvis
Hernias should be repaired at the time of catheter insertion
Laparoscopic placement affords ability to perform adhesiolysis, assess for occult
hernias, and perform omentopexy if necessary. Omentopexy should be performed with
pendulous omentum
Complications of peritoneal dialysis catheters and their treatment
Complication
Peritonitis
Characteristics
Gram-positive cocci,
enteric gram-negative
bacteria, and fungi
Present with abdominal
pain and cloudy dialysate
Intraperitoneal administration of a cephalosporin/
vancomycin+aminoglycoside
Remove catheter if: No response to treatment within 4–5days
of treatment, fungal peritonitis, or peritonitis associated with
intra-abdominal pathology
Management
• Treat constipation
• If no mechanical obstruction, brinolytic therapy with
heparin or tissue plasminogen activator may be attempted.
if fails, proceed with laparoscopic stripping of brin sheath
Laparoscopy can be used to manipulate catheter. Cather
displacement often caused by pendulous omentum adhering to
catheter and “pulling” the catheter tip from the pelvis.
Revision should involve omentopexy. If previous omentopexy
failed, consider omentectomy
Catheter dysfunction
Most common cause is
outow failure resulting
from constipation
Kink in tubing (diagnosed
by KUB)
Displacement into the left
upper quadrant
Biliary System
AmirH.Sohail, SuedehRanjbar,
CarolineE.Williams, CrisMalino, andPareshShah
2
A. H. Sohail (*) · S. Ranjbar
General Surgery Residency, NYU Long Island
School of Medicine, NYU Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: amir.sohail@nyulangone.org; suedeh.
ranjbar@nyulangone.org
C. E. Williams
General Surgery Residency, University of Central
Florida/HCA Healthcare, Pensacola, FL, USA
e-mail: caroline.williams2@ucf.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_2
C. Malino
Department of Surgery, NYU Grossman, NYU
Langone Hospital, New York, NY, USA
e-mail: christine.malino@nyulangone.org
P. Shah
NYP and Coo Weill Cornell Division, New York
Presbyterian and Weill Cornell, New York, NY, USA
e-mail: pshah@nyp.org
33
34
II
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Anatomy ofBiliary Tree
Vascular supply of the biliary system
Biliary tree is supplied by arterial anatomy
The distal CBD (below the level of the duodenal bulb)
➔supplied by the posterosuperior
pancreaticoduodenaland gastroduodenal arteries
The supraduodenal CBD and common hepatic duct
➔supplied by the right hepatic and cystic artery
The arterial blood supply runs along the common
bileduct at the 3 and 9 o’clock positions
40–45% aberrant anatomy
Accessory or replaced right hepatic artery passes
through the portacaval space and ascends to the
rightlobe along the posterolateral aspect of the
commonbile duct
Most commonly originating from SMA, can arise
fromceliac axis or GDA
Right hepatic
artery
9 o’clock
marginal
Posterosuperior
pancreaticoduodenal
artery
artery
A. H. Sohail et al.
3 o’clock
marginal
artery
Gastroduodenal artery
Common hepatic artery
A pulsatile structure on the most lateral aspect of
theporta during a Pringle maneuver identies this
anomaly
Bile ducts
Common hepatic duct branches into the left and right
main hepatic ducts
Left hepatic duct has a longer extrahepatic course
➔splits into segments 1, 2,3, and 4
Right hepatic duct is short and splits early into the
rightanterior (segment V, VIII) and right posterior
ducts(segments I, VI, VII)
To expose hepatic ducts➔the technique of lowering
thehilar plate is utilized by incising Glisson capsule at
itsbase and elevating the quadrate lobe
Anatomic variations seen in up to 30% of patients
VII
Replaced
Right Hepatic
Artery
VIII
V
Right Posterior
VI
Right Anterior
Duct
Duct
Right Hepatic
Duct
I
Left Hepatic
Duct
III
IV
The most common variation involves the right biliary
system➔either the right anterior or right posterior duct
drains directly into the common hepatic duct. Watch for
cystic duct insertion to right hepatic artery
2 Biliary System
Anatomy of the gallbladder
Gallbladder is an extrahepatic reservoir of bile
(holds 30 to 60mL of bile)
35
The cystic duct drains the gallbladder
The cystic duct differs from the other bile ducts
with the presence of the spiral valves of heister,
which may affect ease of transcystic CBD
exploration
Gallbladder is divided into the neck, infundibulum
with Hartmann pouch, body, and fundus
Cystic artery arises from the right hepatic artery
Anatomy of portal triad
Porta hepatis is the area under the liver by segment
4b/5 where the portal triad enters the liver
Conguration in portal triad: Portal vein posteriorly,
CBD anterolateral, hepatic artery anteromedial
The right hepatic artery usually travels posterior to the
CBD
Hepaticoduodenal ligament extends from the porta
hepatis to the duodenum and contains the portal
triad
Neck
Body
Fundus
Common Hepatic Duct
Hartmann’s
pouch
Right Hepatic Artery
Left Hepatic Artery
Portal Vein
Proper Hepatic Artery
Transverse scanning of portal triad➔“Mickey mouse”
view
Gray-scale ultrasound image of the abdomen
demonstrated the portal vein (arrow), hepatic artery
(arrowhead), and common bile duct (curved arrow) in
their normal anatomic arrangement, giving the
appearance of a “Mickey Mouse” sign
36
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Ultrasound oftheBiliary Tree
Sonographic features that differentiate portal veins from hepatic veins
Hepatic veins Portal veins
Orientation Vertically oriented Horizontally oriented
A. H. Sohail et al.
Echogenicity
Location Hepatic veins are a landmark separating the liver
segments➔INTERSEGMENTAL vessels
Flow Hepatofugal ow (drain blood into IVC) Hepatopetal ow (carry blood toward liver)
Radiology
Gray-scale ultrasound image of the liver
demonstrates the hepatic veins (arrows) and
inferior vena cava (star).
Low level wall echoes Periportal brofatty tissue produces brighter
echoes around the portal veins (extension of
Glisson’s capsule entering the liver surrounding
the portal triad causing the brighter echoes)
Run through the middle of the liver
segments➔INTRASEGMENTAL vessels
Gray-scale ultrasound images of the liver
demonstrate the portal vein (arrow). Note the
CBD anterior to the portal vein
Cholecystitis
Type Pathophysiology Radiology
Biliary colic Temporary blockage of the cystic duct or
common bile duct by gallstone➔intense
spasmodic pain in RUQ
• No inammatory process and spontaneous
resolution of pain and tenderness
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