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Rocque’s maneuver may be useful: extend the skin incision up and
laterally; then extend the split of the external oblique aponeurosis and
follow this with a muscle-splitting incision of internal oblique and
transverse muscles above the internal ring. Through this incision you
enterthe peritoneal cavityandreduce the herniatedviscera from within
(likeatlaparoscopy).
The question of the type of hernia repair to be employed is a
matterfortheindividualsurgeon,withoneproviso—inthesedays
oftension-freehernia repair,it seemsimprudenttoplacelarge amounts
of mesh in the groin if necrotic gut has had to be resected. In this
situation some other type of repair seems advisable to obviate the
prolongedmiseryofinfectedmesh.
Femoralhernia
You can approach the acute femoral hernia from below the
inguinalcanal,fromabove,orthroughit.
With the low approach, you place the incision below the inguinal
ligament, directly over the bulge. You find the hernial sac and open it,
making sure to grasp its contents for proper inspection. Strangulated
omentum may be excised and viable bowel is reduced back into the
peritoneal cavity through the femoral ring. When the ring is tight, and
usuallyitis,youcanstretchitwithyoursmallfinger,insertedmediallyto
the femoral vein; occasionally, you’ll have tocut thelower fibers of the
overlyinginguinalligamenttoletyourfingerenterthefemoralcanal.You
can resect non-viable small bowel through this approach and even
anastomose its ends, but pushing the sutured or stapled anastomosis
backintothe abdomenis liketryingtosqueezea tomatointoacocktail
glass.Therefore, when bowel has to beresected, it is advisable to
doitthroughasmallright(or left)lowerquadrant muscle-splitting
laparotomy(asforappendectomy).
Someauthoritiesfavoranapproachviatheinguinalcanalbutwesee
littlemeritinthisapproach,whichmustdisrupttheanatomyofthecanal
andpresumablyrisksasubsequentinguinalhernia.
Yet another approach is McEvedy’s. This involves access to the
extraperitonealspacealongthelateralborderofthelowerpartofrectus
abdominis. The skin incision may be vertical, in line with theborder of
rectus, or oblique/horizontal. A vertical skin incision has the merit of
allowingextensiontoapointbelowtheinguinalligamentandthismaybe
helpful in reducing stubborn hernias, allowing traction from above and
compressionfrombelow.Oncethespace behindtherectusmusclehas
beenaccessed,theherniacanusuallybefreedfrombehindtheinguinal
ligament. The peritoneum can be opened as widely as necessary to
permit inspection of the contents of the hernia sac and to carry out
intestinalresectionifthatisrequired.
Alloftheabove approaches are reasonable provided the contentsof
the hernia sac are examined and dealt with appropriately. As with
inguinal hernias, the implantation of large amounts of mesh should be
avoided in patients who have contamination of the operative field with
intestinal contents. With this caveatthe choice of repair isnot different
from what you would do in the elective situation. Our choice: in the
absence of gross contamination, the femoral canal is obliterated
with a mesh plug. When gross contamination is present, we would
‘close’thefemoralcanalbysuturingtheinguinalligament,above,tothe
pectinealfascia,below.
Incisional/ventralhernias
Incisionalhernias are commonbutmost are asymptomaticexceptfor
the unsightly bulge and discomfort they sometimes produce. It is the
smallincisionalhernias(orthesmallseptatecompartmentswithina
largehernia)withthe tight neck that become acutely symptomatic
—incarceratingomentumorintestine.
The presentation is well known to you: an old ‘silent’ hernia or
abdominal scar, which has now become painful. When bowel has
beenincarceratedtheremaybeassociatedsymptomsofsmallbowel(or,
rarely, colon) obstruction. The hernia itself is tense, tender and nonreducible.
It is important to decide whether the intestinal obstruction is
causedbytheincisionalherniaorsimplyassociatedwithit( Figure
22.2). The latter situation, which is not uncommon, implies that the
patientsufferssmallbowelobstruction,duetoadhesionsforexample,
andtheobstructedanddistendedloopsofbowelinvadethelongstanding
incisional hernia as a secondary phenomenon. On examination, the
bowel-filledtenderherniamaymimicincarceration.Itisforthisreason
thatthecontentsofanyherniaassociatedwithobstructionmustbe
examinedcarefullyatoperationtoensurethattheherniatrulyisthe
causeoftheobstruction(Thisappliestoallkindsofhernias.Werecall
a case of obstruction that was addressed by reducing and repairing a
tense femoral hernia, only for the obturator hernia, which was thetrue
causeoftheobstruction,tobediscoveredatlaparotomymanydayslater
whenthepatientfailedtorecoverfromthefirstoperation.)
Obviously,withliberaluseofpre-operative CT imaging,thesiteofobstructionand the
natureofthecontentsoftheherniacanbeaccuratelydelineated,providingaroadmap
forsurgery.
Figure 22.2. Professor of surgery to assistant: “Just reduce the hernia and repair with
lightmesh…”Amedicalstudent:“ExcusemeSir,butdidyouseethepre-opCT?”
Any‘acute’incisionalherniaisasurgicalemergency.This isalso
truewithothertypesofabdominalwallhernias,suchasparaumbilicalor
epigastric ones. It should be noted, however, that epigastric hernias
rarely, if ever,cause trouble.They contain onlyextraperitoneal fat from
thefalciformligament,andforthisreasonneednotberepairedroutinely
in the absence of symptoms. Also, the acutely incarcerated umbilical
herniaisunlikelytoinvolveintestine.
At operation, the hernia sac has to be entered to evaluate the
incarceratedcontentsthataretobereducedorresecteddependingon
the findings. And the surgical findings should explain the clinical
presentation.For example, ifyou do not findstrangulated omentum or
bowelinthesac,youhavetoretrievethewholelengthoftheintestinein
searchfordistalsmallbowelobstruction.Ifyoufindpuswithinthesac
youhaveto look for the source.Wehave seen patients operatedupon
fora‘strangulatedincisional hernia’whentheunderlyingdiagnosiswas
perforated appendicitis. We have operated for ‘strangulated femoral
hernia’to find the herniasac full ofpus originating froma tubo-ovarian
abscess.(Again,thishintsattheusefulnessofapre-operativeCTscan!)
Afterthecontentsoftheherniahavebeendealtwith,identifythe
fascialmarginsofthedefect.Useyourconventional‘best’repairbutdo
not forget that placing a mesh in a contaminated field is potentially
problematic.Noteverybodyagreeswithsuchdogmaandtherearethose
who do report ‘reasonable’ results with implantation of non-absorbable
meshinacutesituationsandeveningrosslycontaminatedfields—after
resectionofbowel.
Afewcaveatsshouldyouplantousesyntheticmesh:
•
In contaminated fields use polypropylene (e.g. Marlex®) which is
relatively resistant to infection rather than polytetrafluoroethylene
(PTFE—Gore-Tex®)whichisnot.InfectedMarlex®graftsareoften
salvageable while infected Gore-Tex® patches always have to be
removed. The ‘lighter’ and more porous the mesh — the less
susceptibleitistoinfection!
•
Bearinmindalsothatleavingnon-absorbablemeshincontact
withthegutleadstodifficultiesanddisasterslater.Meshrepair
of an incisional hernia should always aim to place the prosthetic
material outside the peritoneum, ideally in the pre-peritoneal
retromuscularposition.Attheveryleastomentumshouldbeplaced
between any unavoidable intraperitoneal mesh and the viscera.
Experience with subsequent laparotomies in patients with
intraperitoneal mesh shows that adhesions are much denser than
with extraperitoneal mesh and as a result small bowel resection is
oftenrequiredsimplytoaccessthe abdominalcavity.And although
uncommon we have all seen spontaneous intestinal fistulas
developingatthecontactpointwiththemesh.Themanufacturersof
the‘dual’-typemesh(smoothorcoatedontheinside,porousonthe
outside) claim that their products are safe for intraperitoneal use;
however,injurytobowelhasalsobeenobservedwithsuchtypesof
mesh.
•
Arelativelynewlyavailableproducttorepairabdominalwallhernias
incontaminatedfields are one of the biomaterials which although
resistanttoinfectionarepronetolateformationof‘weaknesses’and
‘bulges’oftheabdominalwall.
Parastomalherniasareaparticulartypeofincisionalherniawithextra
problems.Theprinciplesofmanagementherearethesameasforother
ventralhernias.Ifa‘clean’operationispossible—nonecrosis,nobowel
resection — then a definitive hernia repair might be attempted. The
Sugarbakermethodseemsthemostfavored:anintraperitonealmesh
isplacedtowidelycoverthestomaopening,andthebowel,onitswayto
the stoma, is ‘parietalized’ — it is placed between the mesh and the
abdominal wall. Combination of this repair, together with a slit-mesh
placed around the bowel (called together ‘the sandwich technique’),
yieldsthehighestsuccessrate.
For a long and detailed assessment of the evidence in emergency
hernia repair, see the World Society of Emergency Surgery guidelines
here:www.wses.org.uk/pdf/compl%20her%20gl.pdf.Itisnotablethatthe
recommendations are mostly level ‘C’, i.e. based on weak (or no)
evidence!
Inacriticallyillpatient,whentherepairisdeemedcomplexoris
judged to increase the intra-abdominal pressure significantly, we
would simply close the skin — leaving the patient with a large
incisionalhernia. Wehave seenpatients dying fromrespiratory failure
prompted by the abdominal compartment syndrome after herniated
contentswerestuffedbackintotheabdomen!Remember—patientsdo
not die from the hernia but from its intestinal complications or a
closurethatistootight.
The place of laparoscopy in acute hernia surgery is expanding as
experience with laparoscopy in the surgical community develops.
Laparoscopyis simply adifferentmethodofachieving the sameresults
asinopensurgery.Thesameprinciplesapply.Twofactorsareimportant:
the skill and experience of the laparoscopist and the condition of the
patient.Thisisnotsurgerytobeattemptedbyabeginnerinlaparoscopy.
Neither is it suitable for a patient withextensive comorbidities and who
might not be able towithstand a prolongedprocedure orthe additional
insult of a pneumoperitoneum. Choose carefully. At least in our place
laparoscopyisnotwidelyusedinemergencysurgeryforherniasevenif
wedoalotofelectivelaparoscopicherniasurgery.
“Alwaysexploreincasesofpersistentvomitingifalump,
howeversmall,isfoundoccupyingoneoftheabdominal
ringsanditsnatureisuncertain.”
AugustusCharlesBernays
Chapter23
Acuteappendicitis
RolandE.Andersson
1
Thischapter hasbeensubdivided intothefollowingtwo
sections:
1.
Acuteappendicitis.
2.
Laparoscopicappendectomy.
1
Acuteappendicitis
RolandE.Andersson
Icannotseewhatharmhasbeendoneiftheappendixhas
been removed. The perfect man is the man without an
appendix.
R.H.Harte
We all know: “Whatever the clinical presentation, whatever the
abdominal findings, always keep acute appendicitis at the back of your
mind.”
Acute appendicitis (AA) is among the first diagnoses that a surgeon
hasto master.Hemay soon findhisway throughthecomplex mazeof
history,clinical and laboratory evaluation,and diagnostic imagingtoget
hispersonalwayofhandlingthesepatients.Mostsurgeonssoonbecome
‘experts’on AA or so they think — oftenwithstrong opinions based on
personalexperience.Asaconsequence,therearewidevariationsin
howthisgroupofpatientsismanaged,notonlyovertheworldbut
alsobetweenindividualsurgeons—differentculturalandeconomic
situations also play a role. All this impedes the establishment of
generallyacceptedguidelinesonhowtomanagepatientswithsuspected
AA.
Why the treatment of obstruction, strangulation, or
perforation of the part of the intestine known as the
vermiform appendix should have given rise to such a
confusion of creeds, such a pandemonium of assertions,
doubts, and arguments is not altogether easy to
understand.
CharlesA.Balance
Sowhat can wetellyouthat youdonotalready know?Perhaps
nothing.But let us emphasize afewpoints—tryingtowipe out a
fewdogmasfromyourhead:
•
Untreated appendicitis does not necessarily progress to
perforation. Many cases of mild, simple AA can resolve without
treatment. This, often forgotten, natural history of appendicitis has
importantimplicationsonhowwethinkaboutandshouldtreatAA.
•
Appendicitis cannot be confirmed or excluded by any single
symptom,sign or laboratory finding. The opposite istrue: the
whole clinical picture and thevarious laboratoryparameters ofthe
inflammatoryresponsehavetobeconsideredtogether.
•
Thesynthesisof clinical and laboratory findings can be made
moreobjectivewiththehelpofadiagnosticscore.TheAlvarado
Score is the best known but has been outperformed by the
Appendicitis Inflammatory Response (AIR) — this is the score
thatwe use( Table23.1).Remember:the score can supporta
decisionbutclinicaljudgmentisstillneededineverycase!
•
Patients with a suspicion of appendicitis are heterogeneous.
We cannot use a single approach for all, but need to vary the
management depending on the clinical presentation and the
perceivedprobabilityofperforation.
•
Appendicitis is associated with a dynamic inflammatory
response.Therefore,ifthediagnosisisunclearatpresentationitis
worthwhile reassessing the patient after a few hours of
observation.
•
Imaging is important in selected cases, not only for diagnostic
accuracy but also to rule out other conditions like ureteral stone,
acutesigmoidorcecaldiverticulitis,ovariantorsion,Crohn’sdisease
orpelvicinflammatorydisease.
Resolvingappendicitis?SimpleAAprogressingtoperforation?
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