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6
Peritoneal neoplasms
L. Amodu et al.
A combination of surgery (cytoreduction) and direct hyperthermic intraperitoneal
chemotherapy (HIPEC) (to remove remaining tissues)
Cytoreduction HIPEC
Complete cytoreduction is the surgical goal Heating the chemotherapy is to increase
the depth of penetration into residual
disease
Resection of gross disease >2mm in size is
possible+peritonectomy of involved areas
Management
Resection can be limited by extensive small
bowel or porta hepatis involvement
Cytoreduction is measured by a
cytoreduction score (CC score)
Contraindications to HIPEC:
Tumors that are not surface nodules on the peritoneum (intrahepatic metastasis or a
pancreatic or bile duct tumor) and retroperitoneal tumors
Patients whose disease is too extensive to achieve complete cytoreduction with the
exception of patients with LAMN because incomplete cytoreduction can still be
benecial in terms of symptom control)
Research
Reference Findings
Sugarbaker PH.Cytoreductive surgery and
hyperthermic intraperitoneal chemotherapy in the
management of gastrointestinal cancers with peritoneal
metastases: Progress toward a new standard of care.
Cancer Treat Rev. 2016;48:42–9
Dubé P, Sideris L, Law C, etal. Guidelines on the use of
cytoreductive surgery and hyperthermic intraperitoneal
chemotherapy in patients with peritoneal surface
malignancy arising from colorectal or appendiceal
neoplasms. Curr Oncol. 2015;22(2): e100–12
Most common agents for HIPEC include
mitomycin-C, doxorubicin, and
oxaliplatin
The most important of the prognostic indicators for
the management of peritoneal surface malignancy is
the completeness of cytoreduction score
Cytoreduction should be planned according to the
area at risk of incomplete resection. The area of the
abdomen at highest risk of incomplete resection
should be addressed rst, because it serves as an
indicator that the procedure should be stopped if the
resection is not possible
1 Abdomen andHernia
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Umbilical andEpigastric Hernia
Differential for midline hernias
Type Characteristics
Umbilical hernia Occurs at the level of the umbilicus
Diastasis recti • Oblong bulge extending along entire midline
• Not a true hernia but a weakening in linea alba with separation of recti but there is
no fascial defect
Epigastric hernia Occurs anywhere between xiphoid process and umbilicus
Repair of umbilical hernia
Most umbilical hernias are repaired in an open approach (periumbilical incision or
small vertical incision)
Use of mesh for hernias >1cm in size signicantly decreases recurrence rate
Management
For defects <1cm consider mesh for patients on peritoneal dialysis, future pregnancy,
or patients who engage in rigorous physical activity
Minimally invasive repair is recommended for: Patients with obesity, DM, smoking,
and recurrent hernias
7
Umbilical hernia with ascites
Incidence Cirrhosis patients with ascites have 40% lifetime risk of developing umbilical hernia
Management Hernia repair is the standard of care, but optimal timing is crucial and outcomes
depend on aggressive control of ascites before elective repair
Case scenario Management
Strangulated hernia+ascites Urgent repair
Reducible hernia+ascites Medical correction of ascites before
repairing
Hernia+ascites refractory to medial
management
Use of mesh is not contraindicated
A patent umbilical vein should not be ligated if encountered. A substantial portion of
the patient’s splanchnic ow may be diverted through such a vein, and ligation can
cause decompensation
TIPS then repair
8
Research
L. Amodu et al.
Reference Findings
Kaufmann R, Halm JA, Eker HH, Klitsie PJ etal.
Mesh versus suture repair of umbilical hernia in
adults: a randomised, double-blind, controlled,
multicentre trial. Lancet. 2018;391(10123):860–9.
https://doi.org/10.1016/S0140- 6736(18)30298- 8.
Epub 2018 Feb 17. PMID: 29459021
Madsen LJ, Oma E, Jorgensen LN, Jensen
KK.Mesh versus suture in elective repair of
umbilical hernia: systematic review and metaanalysis. BJS Open. 2020;4(3):369–79. https://doi.
org/10.1002/bjs5.50276. Epub 2020 Apr 6. PMID:
32250556; PMCID: PMC7260408
Different mesh types and uses
Mesh types
Polypropylene mesh
Characteristics
Permanent synthetic
mesh
Monolament
Macro vs microporous
After a maximum follow-up of 30months, there were
fewer recurrences in the mesh group than in the suture
group (six [4%] in 146 patients vs 17 [12%] in 138
patients; 2-year actuarial estimates of recurrence 3·6%
[95% CI 1·4–9·4] vs 11·4% (6·8–18·9); p=0·01, hazard
ratio 0·31, 95% CI 0·12–0·80)
Compared with suture repair, mesh repair was associated
with a lower risk of recurrence (RR 0·48, 95% CI
0·30–0·77). Mesh repair was associated with a higher risk
of seroma (RR 2·37, 1·45–3·87). There was no signicant
difference in the risk of SSI, hematoma, or chronic pain
Advantages and disadvantages
• Becomes incorporated into tissues
• Low rate of hernia recurrence
• Cannot be placed against bowel (ingrowth into
bowel and stulization)
• Inexpensive
• Macroporous has less foreign body, less
inammatory inltrate, and better tissue
incorporation than microporous mesh. Microporous
mesh has better tensile strength
Polyester
Gore-Tex or
polytetrauoroethylene
(PTFE) mesh
Coated polypropylene mesh
Biological mesh (polyglycolic
acid mesh Integra, Porcine,
ACell, Strattice)
Synthetic absorbable mesh
(BioA, Phasix)
Braided monolament • Progrip® self-afxing and allows tack-free xation
• Allows for more efcient placement
• Can be placed directly into peritoneum against
bowel
Heavyweight
multilament
Has monocryl or
polysaccharide barrier on
the bowel side to resist
adhesion formation
Made of treated organic
material
Biologic, knitted,
monolament mesh
• Smooth and strong
• Poor tolerance to contamination
• Does not become incorporated into tissues,
encapsulates rather than tissue ingrowth
• Contraction over time which leads to recurrence
• Used when mesh is placed in peritoneal cavity
(IPOM)
• Expensive
• Infection resistant
• Used in contaminated elds
• Expensive
• Less risk of infection but a higher risk of recurrence
• Do not use in bridging repairs
• Worse long-term outcomes than synthetic
non-absorbable
• Can be used in contaminated elds
Spermatic cord
inguinal
al abdominal
Testicular
c
(Thomson’
1 Abdomen andHernia
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Common case scenarios of umbilical hernia
Case scenario Management
9
Small asymptomatic umbilical or epigastric
Does not require repair
hernia
Morbidly obese patient+fat-containing umbilical
or epigastric hernia
Recommend weight loss prior to repair when symptoms are
not severe
Don’t repair during pregnancy
Pregnant patient+hernia
Most of these patients don’t require repair postpartum
because these hernias are small and asymptomatic
Inguinal andFemoral Hernia
Operative anatomy of inguinal and femoral Hernia
Inguinal ligament The inguinal ligament spans from
the ASIS to the pubic tubercle. It
is formed by the infolding of the
inferior edge of the external
oblique aponeurosis
Anterior wall: External oblique
aponeurosis
Inferior
epigastric
vessels
Superfical
Boundaries of
inguinal canal
Posterior wall: Transversalis
fascia laterally; conjoint tendon
medially
• Roof: Arching bers of internal
oblique and transversus
abdominis
llioinguinal
nerve
ring
Ductus (vas)
deferens
artery and vein
Peritoneum
Transversus
abdominis
Internal abdominal
oblique muscle
Extern
oblique muscle
Transversalis fa scia and
the deep inguinal ring
Conjoint tendon
Inguinal canall
Inguinal Ligament
• Floor: Inguinal ligament;
Femoral Vessels
medially lacunar ligament
Inguinal Ligament
• Deep inguinal ringtransversalis fascia
Inguinal rings
• Supercial ring-external
oblique aponeurosis
Iliopubic tract/
ilioinguinal
ligament/
Poupart’s
ligament
An aponeurotic band that begins
at ASIS and inserts into Cooper’s
ligament from above
lliopubic
ligament
s)
ligament
Inguinal
Cooper’s
ligament
Lacunar
ligament
Deep
inguinal ring
Fascia
transversalis
Inferior epigastri
artery
Interfoveolar
(Hesselbach’)
ligament
10
Pe
e
of doom
Preperitoneal space
Operative anatomy of inguinal and femoral Hernia
L. Amodu et al.
Cooper’s ligament
(pectineal
ligament)
Is the lateral portion of the
lacunar ligament that is fused to
the periosteum of the pubic
tubercle
Conjoint tendon Medial bers of the internal
oblique aponeurosis unite with the
deeper bers of the transversus
abdominis aponeurosis
Femoral canal Found medial to the femoral vein
and is bounded by the iliopubic
tract anteriorly, the Cooper
ligament posteriorly, and the
lacunar ligament medially
Cooper’s
ligament
Anterior
superior
iliac spine
Lateral
cutaneous
nerve of thigh
Femoral nerve
Femoral artery
lliacus
External oblique
Femoral canal
Femoral vein
Pectineus
Inguinal ligament
lliopubic tract
Intercrural fibers
Lacunar ligament
Superficial
inguinal
ring
Public
tubercle
ritoneum
Median
umbilical ligament
Medical
umbilical
ligament
Lateral umbilical
ligament
Cooper’s
ligament
Femoral Hernia
(peritoneum removed)
Linea semicircularis
External iliac
vessels
Hesselbach
triangle
Triangle
lliopubic tract
Inferior epigastric vessels
Genitofemoral
nerve
Direct Inguinal
Hernia
Testicular vessels
Deep inguinal ring
Vas deferens
Indirect Inguinal
Hernia
Genital branch of
genitofemoral
nerve
Femoral nerve
Femoral branch
of genitofemoral
nerve
Lateral femoral
cutaneous nerve
Triangle
of pain
llioninguinal nerve
lliohypogastric nerv
Laparoscopic
view
The indirect hernia site is through
the internal inguinal ring and
lateral to the epigastric vessels
The direct hernia site is medial to
the internal inguinal ring and
epigastric vessels
Femoral hernia site is medial to
the femoral vein and posterior to
the inguinal ligament and anterior
to Cooper’s ligament
Hernia sac The sac is an extension of
peritoneum typically located
anterior and medial to the
spermatic cord
Cord lipomas are comprised of
preperitoneal fat and usually
located lateral to cord structures
Inferior epigastric
e
1 Abdomen andHernia
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Nerves of ilioinguinal region and Injuries
11
Nerve
Ilioinguinal
(T12, L1)
Iliohypogastric
(T12, L1)
Genitofemoral
nerve (L1, L2)
Lateral femoral
cutaneous
(L2, L3)
Location Innervation
Accompanies spermatic
cord
Anterior cutaneous branch:
Proximal and medial thigh
Mons pubis and labia
majora
Root of penis and upper
scrotum
Skin of hypogastric region More common in open repairs
Open repairs: Entrapment of the
ilioinguinal nerve
Particularly susceptible when
incising and opening the external
oblique aponeurosis
Injury
Between internal oblique
and external oblique
Lateral cutaneous branch:
Skin of gluteal region
Pierces internal and
external oblique above
iliac crest
Genital branch: Passes
through internal ring
Femoral branch: Above
external iliac artery
Mons pubis and labia/
scrotum
Can be injured during open and
laparoscopic repairs
Anterolateral thigh More common in laparoscopic
repairs
Beneath inguinal ligament Anterolateral thigh Laparoscopic repair: Entrapment of
lateral femoral cutaneous
Meralgia paresthetica: Paresthesia
involving the outer thigh due to
external compression of the lateral
femoral cutaneous nerve. Obesity and
tight clothing are predisposing factors
Vessels
Internal
inguinal ring
Inguinal ligament
Femoral artery
Femoral vein
Femoral
ring
Differentiating between inguinal and femoral hernias
Direct inguinal hernia Indirect inguinal hernia
Anatomy Passes through the abdominal
wall layers medial to inferior
epigastric vessels
Physical
exam
Hernia will move from deep to
supercial
Passes through internal inguinal
ring to supercial inguinal ring
Hernia will move from lateral to
medial in inguinal canal
Rectus abdominis
muscle
HESSELBACH’S
TRIANGLE
lliohypogastric nerve
Genital branch
of genitofemoral nerv
llioinguinal nerve
External
inguinal ring
Spermatic
cord
Femoral hernia
Bulge below inguinal ligament
Hernia below inguinal canal
12
Differentiating between inguinal and femoral hernias
L. Amodu et al.
Femoral hernia
Hernia sac located lateral to
the pubic tubercle associated
with venous compression
Imaging
Direct inguinal hernia Indirect inguinal hernia
Hernia sac extends medial to the
Inguinal canal contents are
compressed and stretched
laterally by the hernia➔the
normal fat of the inguinal canal
is pushed into a semicircle of
tissue that resembles a moon
crescent
pubic tubercle
Inguinal and femoral hernias
Risk factors Male sex, increased age, increased intra-abdominal pressure, such as chronic cough and benign
prostatic hyperplasia, collagen disorders
Indirect inguinal hernia is the most common groin hernia in both sexes
Men are 8× more likely to develop a hernia and 20× more likely to need a hernia repair
compared with women
General
characteristics
Presentation
96% inguinal and 4% femoral
Femoral hernias present clinically with complications more often than inguinal hernias
Femoral hernias represent 20–30% of repairs in women compared with only 1% in men
Femoral hernias are more common in women than in men (10:1)
Femoral hernias have the highest risk of incarceration (15–20%)
A sliding hernia sac includes the visceral peritoneum of a retroperitoneal organ such as the
colon
Most common nding is a groin bulge
Two-thirds of patients will have symptoms of pain or vague discomfort, and one-third are
asymptomatic
1 Abdomen andHernia
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Inguinal and femoral hernias
Examine patient in the standing position
The external inguinal ring can be examined by invaginating the scrotum or labia majora and
placing a nger in the inguinal canal
A hernia that cannot be reduced is as an incarcerated hernia
13
Diagnosis
Management
Strangulation is most common in large hernias with a small neck
Signs of strangulation include skin changes like warmth and erythema, a tense bulge, severe
tenderness, and symptoms of bowel obstruction
In a patient with a groin mass, examine the entire lower extremity for a lesion that could lead to
lymphadenopathy➔Suspicion of lymphadenopathy should prompt examination of the entire
lower extremity, abdomen, perineum, and anus
Nonoperative management in patients with asymptomatic or minimally symptomatic inguinal
hernias carries a low risk of incarceration (0.3% in a 2-year study)
For sliding hernias: Traditional approach was to open sac, identify, and reduce the
intraperitoneal structure, and then redundant sac would be excised and closed in an open repair,
or reduced completely and freed from the spermatic cord in laparoscopic repair. Newer school
of thought is that a high dissection followed by reduction of the sac is more favorable to high
ligation as it may reduce postoperative pain
Open vs laparoscopic inguinal hernia repair
Open
Advantage Shorter operative time, decreased cost,
easier to become technically procient
Disadvantage More postoperative pain, longer recovery
time
Laparoscopic
Shorter recovery time, less postoperative pain,
and ability to repair multiple hernia types
Higher risk of vascular or visceral injury
including rare serious injuries
Research
Reference Findings
Bradley M, Morgan D, Pentlow B, Roe A.The
groin hernia—an ultrasound diagnosis? Ann R
Coll Surg Engl. 2003;85(3):178–80
To diagnose hernia, ultrasonography can be performed with
the Valsalva maneuver and is known as dynamic
ultrasonography. This modality is highly sensitive
(86–97%) and specic (87–97%) in identifying occult
inguinal hernias
Imaging is not necessary for many patients, and operative
exploration without imaging may be appropriate in some
instances
14
Research
L. Amodu et al.
Reference Findings
Fitzgibbons RJ Jr, Ramanan B, Arya S, etal.
Investigators of the Original Trial. Long-term
results of a randomized controlled trial of a
non-operative strategy (watchful waiting) for men
with minimally symptomatic inguinal hernias. Ann
Surg. 2013;258(3):508–15
de Goede B, Wijsmuller AR, van Ramshorst GH,
etal.. INCA Trialists’ Collaboration. Watchful
waiting versus surgery of mildly symptomatic or
asymptomatic inguinal hernia in men aged 50 years
and older: a randomized controlled trial. Ann Surg.
2018;267(1):42–9
HerniaSurge Group. International guidelines for
groin hernia management. Hernia.
2018;22(1):1–165
Fitzgibbons RJ, Jr, Forse RA.Clinical practice.
Groin hernias in adults. N Engl J Med.
2015;372:756–63
McCormack K, Scott NW, Go PM, etal. EU Hernia
Trialists Collaboration. Laparoscopic techniques
versus open techniques for inguinal hernia repair.
Cochrane Database Syst Rev.
2003;2003(1):CD001785. https://doi.
org/10.1002/14651858.CD001785. PMID:
12535413; PMCID: PMC8407507
In this RCT, watchful waiting for male minimally
symptomatic inguinal hernia, there was a crossover into the
repair group of 64% at 10years. These ndings led to the
current recommendation that although watchful waiting is a
reasonable approach initially, most men will need eventual
repair of inguinal hernias
The rate of acute incarceration requiring urgent repair
during watchful waiting was low
Women are thought to be at higher risk of incarceration and
strangulation due to the inability of examination or imaging
to reliably differentiate femoral from inguinal hernias➔no
watchful waiting
In primary, unilateral inguinal hernia repairs, recurrence is
more common after laparoscopic repair, particularly total
extraperitoneal (TEP) repair, compared with open repair,
while chronic pain is more common after open repair
Duration of operation was longer in the laparoscopic groups
(WMD 14.81min, 95% CI 13.98–15.64; p<0001).
Operative complications were uncommon for both methods
but more frequent in the laparoscopic group for visceral
(overall 8/2315 versus 1/2599) and vascular (overall 7/2498
versus 5/2758) injuries. No difference was detected when
comparing laparoscopic methods with open mesh methods
of hernia repair
1 Abdomen andHernia
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Types of repairs of inguinal and femoral hernias
15
Types of repairs
Open tissue
repair
Bassini repair
McVay repair
Shouldice repair
Key Steps
• High ligation of sac
• Open oor (transversalis) from internal
ring to pubic tubercle
• Conjoint tendon to Poupart’s Ligament
(“triple layer” internal oblique,
transversus, transversalis fascia to
iliopubic tract)
• First bite through periosteum of pubic
tubercle
Interrupted sutures are used to approximate
the superior leaf of transversalis fascia to
Cooper’s ligament
• Transition stitch
• Repair continued along iliopubic tract to
internal ring
• Requires a relaxing incision in anterior
rectus sheath
Multilayered imbricated repair of posterior
wall of inguinal canal using continuous
running suture technique
• The lesser cord (genital branch of the
genitofemoral nerve and accessory
spermatic vessels) is routinely divided
• The oor of the inguinal canal is repaired
with running sutures
Uses and limitations
Recurrence 2.9–25%
• Addresses femoral hernia
• Recurrence rate 1.5–15%
• Best option among tissue
repair➔lowest recurrence
rates of tissue repairs (2.2%)
• Technically most challenging
• Patient selection required
(height to weight ratio,
non-obese, low muscle mass)
Open mesh
repair
Lichtenstein
Plug and patch
repair
A pocket is fashioned deep to the external
oblique aponeurosis for placement of a sheet
of mesh. Tension free repair relies on
9×14cm tailored mesh rather than suture
repair. A longitudinal slit is made in the
middle of lateral aspect of the mesh,
creating two tails to allow for passage of the
spermatic cord
The edges of the mesh are secured with
running and interrupted sutures, and the two
tails are secured to each other to recreate the
internal ring.
Mesh should overlap the pubic tubercle by
approximately 2cm, and lateral mesh
overlap should be 4–5cm beyond internal
ring
The external oblique is closed over the mesh
and spermatic cord, taking care to avoid
cord and nerve during closure
A mesh plug is placed into the internal ring
before overlying sheet of mesh is placed
Gold standard for open repair
4% risk of chronic pain from
meshoma (ball of wrinkled,
contracted mesh)
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