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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1099_Библиотеки_им_академика_М_И_Перельмана.pdf
Abdominal Wall Reconstruction
Contributors
CONSULTING EDITO R
RONALD F. MARTIN, MD, FACS
Staff Surgeon, Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin; Clinical
Associate Professor, University of Wisconsin School of Medicine and Public Health,
Madison, Wisconsin; Colonel, Medical Corps, United States Army Reserve
EDIT OR
MICHAEL J. ROSEN, MD, FACS
Co-Director, Case Acute Intestinal Failure Unit; Associate Professor of Surgery; Chief,
Division of GI and General Surgery, Department of Surgery; Director, Case
Comprehensive Hernia Center, Case Medical Center, University Hospitals of Cleveland,
Case Western Reserve University, Cleveland, Ohio
AUTH OR S
ANDREA MARIAH ALEXANDER, MD
MIS Fellow/Clinical Instructor, Department of Surgery, Southwestern Center for Minimally
Invasive Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
DONALD P. BAUMANN, MD, FACS
Associate Professor, Department of Plastic Surgery, The University of Texas MD Anderson
Cancer Center, Houston, Texas
CURTIS BOWER, MD
Instructor of Surgery, Section of Gastrointestinal and Minimally Invasive Surgery, Division
of General Surgery, A. B. Chandler Medical Center, University of Kentucky, Lexington,
Kentucky
CHARLES E. BUTLER, MD, FACS
Professor with Tenure, Director, Graduate Medical Education Programs, Department of
Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
ALFREDO M. CARBONELL, DO, FACS, FACOS
Associate Professor of Surgery, Chief, Division of Minimal Access and Bariatric Surgery,
Co-director, Hernia Center, Greenville Health System, University of South Carolina School
of Medicine – Greenville, Greenville, South Carolina
GORDON LAWRENCE CARLSON, BSc, MD, FRCS
Professor, Department of Surgery, National Intestinal Failure Centre, Salford Royal NHS
Foundation Trust, Salford, Manchester, United Kingdom
iv
Contributors
LEANDRO TOTTI CAVAZZOLA, MD, PhD
Assistant Professor, Department of Surgery, Universidade Federal do Rio Grande do Sul,
Bairro Petro´polis, Porto Alegre, Rio Grande do Sul, Brazil
WILLIAM S. COBB, MD, FACS
Associate Professor of Surgery, Vice Chair of Clinical Affairs, Department of Surgery,
Co-director, Hernia Center, Greenville Health System, University of South Carolina School
of Medicine - Greenville, Greenville, South Carolina
RANDALL O. CRAFT, MD
Plastic and Reconstructive Surgery, Division of Surgery, Banner MD Anderson Cancer
Center, Gilbert, Arizona
CLIFFORD W. DEVENEY, MD
Professor, Department of Surgery, Oregon Health and Science University, Portland,
Oregon
DAVID B. EARLE, MD, FACS
Director of Minimally Invasive Surgery and Esophageal Physiology Lab, Department of
Surgery, Baystate Medical Center, Springfield; Associate Professor of Surgery, Tufts
University School of Medicine, Boston, Massachusetts
KRISTI L. HAROLD, MD
Associate Professor, Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
HOBART W. HARRIS, MD, MPH
J. Englebert Dunphy Chair in Surgery, Professor and Chief, Division of General Surgery,
Department of Surgery, UCSF, San Francisco, California
W. BORDEN HOOKS III, MD
Assistant Professor, Department of Surgery, New Hanover Regional Medical Center,
South East Area Health Education Center, University of North Carolina-Chapel Hill,
Wilmington, North Carolina
WILLIAM W. HOPE, MD
Assistant Professor, Department of Surgery, New Hanover Regional Medical Center,
South East Area Health Education Center, University of North Carolina-Chapel Hill,
Wilmington, North Carolina
LEIF A. ISRAELSSON, MD, PhD
Associate Professor, Department of Surgery and Perioperative Science, Umea˚University,
Umea˚; Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden
KATHERINE B. KELLY, MD
Division of Pediatric Surgery, Pediatric Surgery Center, Akron Children’s Hospital, Akron,
Ohio
ROBERT G. MARTINDALE, MD, PhD
Professor and Chief, Division of General Surgery, Oregon Health and Science University,
Portland, Oregon
JENNIFER A. MCLELLAN, MD
Minimally Invasive Surgery Fellow, Department of Surgery, Baystate Medical Center,
Springfield, Massachusetts
Contributors
DANIEL MILLBOURN, MD, PhD
Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden
YURI W. NOVITSKY, MD
Director, Surgical Research, Associate Professor of Surgery, Department of Surgery,
Co-Director, Case Comprehensive Hernia Center, University Hospitals Case Medical
Center, Case Western Reserve University, Cleveland, Ohio
ERIC M. PAULI, MD
Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
TODD A. PONSKY, MD, FACS
Associate Professor of Surgery and Pediatrics, Division of Pediatric Surgery, Pediatric
Surgery Center, Akron Children’s Hospital, Akron, Ohio
MICHAEL J. ROSEN, MD, FACS
Co-Director, Case Acute Intestinal Failure Unit; Associate Professor of Surgery;
Chief, Division of GI and General Surgery, Department of Surgery; Director, Case
Comprehensive Hernia Center, Case Medical Center, University Hospitals of Cleveland,
Case Western Reserve University, Cleveland, Ohio
J. SCOTT ROTH, MD
Professor of Surgery, Section Head, Section of Gastrointestinal and Minimally Invasive
Surgery, Division of General Surgery, A. B. Chandler Medical Center, University of
Kentucky, Lexington, Kentucky
v
DANIEL J. SCOTT, MD, FACS
Professor, Department of Surgery, Frank H. Kidd Jr, MD Distinguished Professorship in
Surgery, Director, Southwestern Center for Minimally Invasive Surgery, University of
Texas Southwestern Medical Center, Dallas, Texas
NILAY R. SHAH, MD, MS
Surgery Resident, Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
DOMINIC ALEXANDER JAMES SLADE, MB ChB, FRCS
Department of Surgery, National Intestinal Failure Centre, Salford Royal NHS Foundation
Trust, Salford, Manchester, United Kingdom
Abdominal Wall Reconstruction
Contents
Foreword: Abdominal Wall Reconstruction xiii
Ronald F. Martin
Preface: Abdominal Wall Reconstruction xvii
Michael J. Rosen
Prevention of Incisional Hernias: How to Close a Midline Incision 1027
Leif A. Israelsson and Daniel Millbourn
The development of wound complications is closely related to the surgical
technique at wound closure. The risk of the suture technique affecting the
development of wound dehiscence and incisional hernia can be monitored
through the suture length to wound length ratio. Midline incisions should
be closed in one layer by a continuous-suture technique using a monofilament suture material tied with self-locking knots. Excessive tension should
not be placed on the suture. Closure must always be with a suture length to
wound length ratio higher than 4.
Preoperative Risk Reduction: Strategies to Optimize Outcomes 1041
Robert G. Martindale and Clifford W. Deveney
The success of hernia repair is measured by absence of recurrence,
appearance of the surgical scar, and perioperative morbidity. Perioperative surgical site occurrence (SSO), defined as infection, seroma, wound
ischemia, and dehiscence, increases the risk of recurrent hernia by at least
3-fold. The surgeon should optimize all measures that promote healing,
reduce infection, and enhance early postoperative recovery. In the population with ventral hernia, the most common complication in the immediate
perioperative period is surgical site infection. This article reviews several
preoperative measures that have been reported to decrease SSOs and
shorten length of hospital stay.
Repair of Umbilical and Epigastric Hernias 1057
David B. Earle and Jennifer A. McLellan
Umbilical and epigastric hernias are primary midline defects that are present in up to 50% of the population. In the United States, only about 1% of
the population carries this specific diagnosis, and only about 11% of these
are repaired. Repair is aimed at symptoms relief or prevention, and the
patient’s goals and expectations should be explicitly identified and aligned
with the health care team. This article details some relevant and interesting
anatomic issues, reviews existing data, and highlights some common and
important surgical techniques. Emphasis is placed on a patient-centered
approach to the repair of umbilical and epigastric hernias.
viii
Contents
Laparoscopic Ventral Hernia Repair 1091
Andrea Mariah Alexander and Daniel J. Scott
Laparoscopic ventral hernia repair (LVHR) has established itself as a wellaccepted option in the treatment of hernias. Clear benefits have been
established regarding the superiority of LVHR in terms of fewer wound
infections compared with open repairs. Meticulous technique and appropriate patient selection are critical to obtain the reported results.
Open Ventral Hernia Repair with Component Separation 1111
Eric M. Pauli and Michael J. Rosen
In this article, the authors describe their current operative technique for
open ventral hernia repair using component separation. Although methods
of anterior component separation are described, in their current practice,
the authors primarily use posterior component separation with transversus
abdominis release to permit dissection beyond the retrorectus space. This
method adheres to the literature-supported principles of a tension-free
midline fascial closure with wide mesh overlap of mesh positioned in a sublay position. The authors’ experience with this method supports a low
recurrence rate and reduced wound morbidity.
Atypical Hernias: Suprapubic, Subxiphoid, and Flank 1135
William W. Hope and W. Borden Hooks III
Thorough knowledge of anatomy, appropriate preoperative planning, and
reliance on the principles of hernia repair ensure successful outcomes.
There are many options for repair, including technique and mesh choice.
The hernia surgeon should be well versed in the open and laparoscopic
approaches and apply them based on the individual clinical prese ntation.
Long-term outcomes related to suprapubic, subxiphoid, and lateral hernia
repairs are limited; however, open and laparoscopic repairs using wide
mesh overlap and adequate fixation have acceptable outcomes and recurrence rates. Future research will likely focus on comparative studies based
on patient factors, techniques, mesh, and cost.
Takedown of Enterocutaneous Fistula and Complex Abdominal Wall Reconstruction 1163
Dominic Alexander James Slade and Gordon Lawrence Carlson
Key steps in managing patients with enterocutaneous fistulation and an
abdominal wall defect include dealing effectively with abdominal sepsis
and providing safe and effective nutritional support and skin care, then
assessing intestinal and abdominal anatomy, before undertaking reconstructive surgery. The complexity, cost, and morbidity associated with
such cases justifies creation of specialized centers in which gastroenterologic, hernia, and plastic surgical expertise, as well as experienced wound
and stoma nursing and nutritional and psychological support, can be made
available for patients with these challenging problems.
Parastomal Hernia Repair 1185
Nilay R. Shah, Randall O. Craft, and Kristi L. Harold
Occurrence of parastomal hernia is considered a near inevitable consequence of stoma formation, making their management a common clinical
Contents
dilemma. This article reviews the outcomes of different surgical
approaches for hernia repair and describes in detail the laparoscopic Sugarbaker technique, which has been shown to have lower recurrence rates
than other methods. Also reviewed is the current literature on the impact of
prophylactic mesh placement during ostomy formation.
Soft Tissue Coverage in Abdominal Wall Reconstruction 1199
Donald P. Baumann and Charles E. Butler
Abdominal wall defects requiring soft tissue coverage can be either partialthickness defects or full-thickness composite defects. Soft tissue flap
reconstruction offers significant advantages in defects that cannot be
closed primarily. Flap reconstruction is performed in a single-stage procedure obviating chronic wound management. If the defect size exceeds the
availability of local soft tissue for coverage, regional pedicled flaps can be
delivered into the abdominal wall while maintaining blood supply from their
donor site. Microsurgical free tissue transfer increases the capacity to provide soft tissue coverage for abdominal wall defects that are not amenable
to either local or regional flap coverage.
Biology of Biological Meshes Used in Hernia Repair 1211
Yuri W. Novitsky
Successful repair of most hernias requires the use of a prosthetic implant
for reinforcement of the defect. Because of the need for prosthetic
implants to resist infections as well to support repairs in contaminated or
potentially contaminated fields, biological meshes have been developed
to take the place of nondegradable synthetic meshes in cases where
mesh infection is of high concern. The ideal is a biological matrix that
resists infection while providing durable reinforcement of a hernia repair.
This article reviews the validity of assumptions that support the purported
notion of the biological behavior of biological meshes.
ix
Clinical Outcomes of Biologic Mesh: Where Do We Stand? 1217
Hobart W. Harris
After review and evaluation of current clinical data, including significant
wound complications, a noteworthy failure rate at 1 year, and high product
costs, it is difficult to support the continued use of biologic meshes in incisional hernia repair outside of well-designed and rigorously conducted
clinical trials. An industry-sponsored, publicly available registry of biologic
prosthetic use for ventral hernia repairs is needed. This straightforward
mandate, if properly constructed and implemented, would significantly
expand knowledge regarding how these intriguing biomaterials are used
and their overall clinical efficacy, thus yielding a more robust basis for
the continued use of biologic prosthetics in hernia repair than is currently
available.
Safety of Prosthetic Mesh Hernia Repair in Contaminated Fields 1227
Alfredo M. Carbonell and William S. Cobb
For years, surgical dictum has posited that permanent synthetic mesh is
contraindicated in the repair of a hernia in a contaminated field. Numerous
x
Contents
investigators, however, have demonstrated the acceptably low morbidity
associated with the use of heavy-weight polypropylene mesh in cleancontaminated and contaminated fields. Recently, experience utilizing
more modern, light-weight polypropylene mesh constructs in contaminated fields has grown considerably. The time has come to critically
reevaluate the unfounded fear of utilizing permanent synthetic mesh in
contaminated fields, as we will review the data speaking to the safety of
mesh in these contaminated fields.
Economics of Abdominal Wall Reconstruction 1241
Curtis Bower and J. Scott Roth
The economic aspects of abdominal wall reconstruction are frequently
overlooked, although understandings of the financial implications are
essential in providing cost-efficient health care. Ventral hernia repairs are
frequently performed surgical procedures with significant economic ramifications for employers, insurers, providers, and patients because of the
volume of procedures, complication rates, the significant rate of recurrence, and escalating costs. Because biological mesh materials add significant expense to the costs of treating complex abdominal wall hernias, the
role of such costly materials needs to be better defined to ensure the most
cost-efficient and effective treatments for ventral abdominal wall hernias.
Pediatric Abdominal Wall Defects 1255
Katherine B. Kelly and Todd A. Ponsky
This article reviews the incidence, presentation, anatomy, and surgical
management of abdominal wall defects found in the pediatric population.
Defects such as inguinal hernia and umbilical hernia are common and are
encountered frequently by the pediatric surgeon. Recently developed
techniques for repairing these hernias are aimed at improving cosmesis
and decreasing pain while maintaining acceptably low recurrence rates.
Less common conditions such as femoral hernia, Spigelian hernia, epigastric hernia, lumbar hernia, gastroschisis, and omphalocele are also discussed. The surgical treatment of gastroschisis and omphalocele has
undergone some advancement with the use of various silos and meshes.
Laparoscopic Versus Open Inguinal Hernia Repair 1269
Leandro Totti Cavazzola and Michael J. Rosen
The laparoscopic approach to inguinal hernia surgery is safe and reliable. It
has a similar recurrence rate as open tension-free mesh repair. Because
the laparoscopic approach has less chronic postoperative pain and numbness, fast return to normal activities, and decreased incidence of wound
infection and hematoma, it should be considered an appropriate approach
for inguinal hernia surgery. These results can be achieved if a surgeon is
proficient in the technique, has a clear understanding of the anatomy,
and performs it on a regular basis. This article focuses on questions related
to laparoscopic inguinal hernia surgery and provides answers based on
published literature.
Index 1281
Abdominal Wall Reconstruction
Foreword
Abdominal Wall
Reconstruction
Ronald F. Martin, MD, FACS
Consulting Editor
Perhaps the most important thing we strive to achieve with the Surgical Clinics of North
America series is to find very capable people who can effectively summarize a vast
amount of material, some or much of it conflicting, and put that material into context.
In essence, we ask our contributors to not only drink from the fire hydrant that has
become our source of information but to give you a report on the quality of the water
and suggest how you can use it to your patients’ advantage. One of the concepts we
always try to particularly consider is whether the ideas that we sometimes cling to most
fervently are actually correct—frequently, they are not.
When I was in my residency, which seems like a long time ago to my current residents and a short time ago to me, people would refer to appendectomies and hernia
repairs as “intern cases.” I would like to submit that in that regard we were dead wrong.
We were wrong then and we are far more wrong now when we make that assertion. We
were wrong then because we assumed, perhaps arrogantly, that all hernia repairs were
“easy.” They are not, even if one is referring solely to inguinal hernias, still not easy.
We were also wrong then because that assumption that each patient presents without
variations that may markedly increase the complexity of repair is intellectually flawed.
We are more wrong today if we claim that these are “intern cases” for multiple reasons:
changes in training, changes in trainees, changes in technology, and changes in
technique.
The training changes are among the most significant. In 2003 the Institute of
Medicine released its “To Err is Human” report that formed the basis for a major
and unprecedented impact on resident work hours regulation. Of course, this was followed in 2011 by the more significant changes to not only further reduce work hours,
Surg Clin N Am 93 (2013) xiii–xv
http://dx.doi.org/10.1016/j.suc.2013.07.002 surgical.theclinics.com
0039-6109/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
xiv
Foreword
for some residents more than others, but also alter on a PGY-specific basis the
degree and type of resident supervision. Without commenting on the merits of these
changes, the net result of this for most programs was a marked decrease of exposure to patients for all residents to some degree but even more impactful on PGY-1
residents. Also lost substantially, but perhaps less often written about, was the
decreased ability (because of work hour constraints, not other regulations) for a senior resident to serve as “teaching assistants,” a role that most certainly focuses the
mind of many surgeons.
The trainees have changed as well. Unless one has been working as a member of a
medical student faculty or a resident training faculty, it might not be as apparent.
Having the opportunity to work in both of those roles, I would suggest that the changes
to medical student education, particularly in regard to ability to assume responsibility
and participate significantly in patient care, have been more dramatic than the
changes in resident education. This has led to a concerted effort to create “surgical
boot camps” and led in part to the diminution of the PGY-1 resident role by the
ACGME. Whether one agrees or disagrees with the changes, one fact remains incontrovertible: some things that used to be learned by most students in medical school
now have to be taught in residency. And we have less time in residency to cover
the same, or more, ground than we used to.
Technology has changed on multiple fronts, although this is certainly not news. In
particular regard to hernia repair, the advent of videoscopic techniques, the emergence and perhaps decline of biological substrates, and changes in physical characteristics of synthetic mesh materials have all altered the landscape. Many of these
changes have significantly changed our approaches to hernia repair in elective,
urgent, primary, reoperative, and even contaminated clinical situations.
Last, at least for this discussion, changes in techniques have played a major role.
Very few of us are left who routinely had to choose between the various eponymous
repairs of Bassini, Shouldice, MacVeigh, or others. Asking a surgical resident today
to describe the benefits or pitfalls of various primary repairs usually elicits a pretty brief
response. It would probably be somewhat amusing to poll a few hundred residents to
see how they would describe relaxing incisions. I have heard some pretty creative
ideas in response to that question. Yet perhaps none of it matters so much. The
concept of the tension-free repair, the changes in material sciences alluded to above,
the ability to insert material by small incision, using either open technique or videoscopic technique, all to some degree or another mute the importance of some
many of the “primary” repairs.
Hernia repairs can be performed easily but they can also strain the patience and
skill of very seasoned surgeons. Add into the conversation the more complicated
ventral hernias and one can really send chills up the spines of those who have
“been there and done that.” I have met very few senior surgeons who would not admit
privately if not publicly that they never felt like they began to understand hernia repairs
until they were a senior resident. Furthermore, most will admit that until they had
performed a fair number as a staff surgeon they had not established a comfort level
with the procedures. Also, almost all will confess that the more hernia repairs they
performed, the more respect they developed for the potential, although thankfully
rare, complications of these “intern cases.”
As always, the best way to shorten the learning curve and to minimize the likelihood of creating potentially avoidable complications is to start by learning what
others have learned. This issue, compiled by Dr Rosen and his colleagues, is an
outstanding review and, perhaps for some, introduction to what one must know to
safely advise patients on when and how their hernias may be treated. We are deeply