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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1498_Библиотеки_им_академика_М_И_Перельмана.pdf
272
S. Philipp
appropriate preparations be made. This includes the possibility of dense
adhesions with involvement of omentum, small and large bowel, and other
intra-abdominal structures. This risk is potentially increased if the patient
has a previous history of serious intra-abdominal infection. Taking down
adhesions is usually necessary for the successful completion of a ventral
hernia repair and can signi fi cantly increase operative times and operative
risk. If one or more previous attempts at hernia repair have already been
made, then this risk is ampli fi ed. The previous placement of mesh can also
add complexity and risk. It is potentially helpful to discover the material,
size, and position of all previously placed pieces of foreign materials, and
this information should be considered during operative planning. The
possibility of mesh migration, contraction, erosion, eventration, and dense
adhesion to intra-abdominal organs should be anticipated.
Morbid Obesity
The incidence of morbid obesity in our communities is growing. The
impact of obesity on hernia surgery is still being investigated although it
is known to be associated with increased hernia recurrence rates [ 1 ] .
There are now several retrospective reviews investigating the impact of
morbid obesity on hernia repair outcomes. The largest study looking at
patients undergoing laparoscopic ventral hernia repair found that a
preoperative BMI greater than 40 imparted an increased risk of recurrence
without increased perioperative morbidity [ 2 ] . The results of several
other smaller studies are divided [ 3– 6 ] . Morbid obesity increases risk for
recurrence and postoperative complications after inguinal hernia repair
as well [ 7 ] . Current expert opinion considers morbid obesity a potentially
correctable risk factor for postoperative complications, and hernia
recurrence and efforts should be made for patients to lose weight prior to
proceeding with an elective hernia repair, ideally to a BMI less than 35.
A recent survey found morbid obesity to be the number one cited
contraindication to ventral hernia repair among surgeons [ 8 ] .
Smoking
The physiologic impact of tobacco smoking has been well-de fi ned. In
addition to its effects on the cardiovascular, pulmonary, and nervous
systems, it can prevent appropriate wound healing and impairs the immune
system. Effects include impaired tissue oxygenation, peripheral
273
23. Patient Comorbidities Complicating a Hernia Repair
vasoconstriction, hyperglycemia, insulin resistance, impairment of growth
factors, and immune modulators, among others. In clinical studies, smoking
has been shown to signi fi cantly increase perioperative morbidity, particularly
wound infection and hernia recurrence, after ventral and inguinal hernia
repair [ 9, 10 ] . It is also a risk factor for development of an incisional hernia
after other operations [ 11 ] . Smoking is a modi fi able risk factor, and
therefore, all efforts should be made to help a patient quit smoking prior to
elective surgery. It should not delay surgery that is urgent or emergent,
although patients should be informed of the impact it could have on their
recovery and outcome. For elective hernia repair in patients at high risk for
perioperative morbidity, preoperative smoking cessation is mandatory in
my opinion, and patient noncompliance should prompt rescheduling at a
later time. Smoking cessation should be for at least 1 month prior to surgery
to avoid increased pulmonary complications [ 12 ] . Compliance can be
veri fi ed by performing a test for urine cotinine, a metabolite of nicotine.
Age
There is no contraindication to elective hernia repair based on age
alone. As the population continues to live longer, more patients will
present with hernias later in life. Surgical repair should be considered if
the expected improvement in patient quality of life exceeds the potential
risks based on other factors.
Diabetes
Hyperglycemia can adversely affect wound healing and the immune
response which increases perioperative morbidity. Patients should have
optimal control of their blood glucose levels before proceeding with an
elective hernia repair. Strict postoperative glycemic control is also
important, especially for more complex hernia repairs. Aggressive therapy
should target blood glucose levels to a range of 80–150 mg/dL [ 13 ] .
Pulmonary Disease
There are two things that need to be considered regarding pulmonary
function prior to proceeding with a hernia repair: fi rst, the impact of
anesthesia—general versus spinal versus local—on the lungs; and second,
274
S. Philipp
the potential impact of the hernia repair on pulmonary function. Patients
with physical limitations due to their disease or those on supplemental
oxygen should avoid general anesthesia if possible. In the case of large
symptomatic abdominal wall hernias in which there is no feasible
anesthetic alternative, the potential risks should be discussed with the
patient and weighed against the expected bene fi ts of the operation.
Operative time should be minimized, and local anesthetic should be used
to reduce narcotic requirements. For large hernias with loss of abdominal
domain, it is important to consider the impact of hernia repair, with
restoration of abdominal contents into the true abdominal cavity, on the
diaphragm. Pulmonary peak inspiratory pressures should be measured
both before and after abdominal wall closure when increased abdominal
pressure due to hernia repair is suspected. A signi fi cant increase in pressure
should prompt reevaluation of the closure technique by the surgeon as this
patient is potentially at risk for post-op pulmonary failure.
Cardiac Disease
Estimation of cardiac risk prior to surgery should be performed based
on current American College of Cardiology (ACC) and American Heart
Association (AHA) guidelines which emphasize three elements: patient-
speci fi c clinical variables, exercise capacity, and surgery-speci fi c risk. A
detailed history and physical examination is necessary to determine need
for further cardiac testing. Elective surgery should be delayed in patients
with active or unstable cardiac disease. Emergent surgery (e.g.,
strangulated hernia) should not be delayed for further cardiac testing as
risk assessment would not alter management.
Chronic Constipation and Urologic Conditions
Ongoing conditions that chronically increase intra-abdominal
pressure should be identi fi ed and treatment initiated prior to elective
hernia repair. Patients with chronic constipation should be counseled to
increase their dietary fi ber intake and prescribed fi ber supplementation
and stool softeners. Colonoscopy should be considered in the appropriate
clinical situations. Those with urinary retention or over fl ow incontinence
should be started on appropriate treatment such that urinary symptoms of
frequency and straining are resolved. Dysuria should be investigated
275
23. Patient Comorbidities Complicating a Hernia Repair
with urinalysis and hematuria with urologic consultation and cystoscopy
prior to elective hernia repair.
Surgeon Experience and Institutional Capabilities
Hernia surgeons are confronted with a wide spectrum of disease,
from simple low-risk operations in young, healthy patients, to technically
complicated operations in patients with multiple comorbid conditions.
There are several approaches to surgical treatment, including open and
laparoscopic techniques, and many options for mesh materials. Surgeon
experience and institutional capabilities are important factors to consider
prior to proceeding with surgical treatment. Mesh materials of appropriate
size should be con fi rmed available prior to starting surgery. Complications
need to be anticipated and plans available should they occur. During
laparoscopic surgery, conversion to open should never be considered
failure if it is done for the bene fi t of the patient. Hernia surgery can be
very complicated and dif fi cult—calling for assistance should be
considered during dif fi cult situations.
Summary
There are many comorbid conditions and other issues to consider
when preparing for a hernia repair. It is important to optimize the patient’s
medical condition(s), nutrition, and overall health prior to proceeding
with repair. Patients should be given realistic expectations regarding
surgical outcomes and have a clear understanding of the goals of surgical
treatment. This is especially important for patients with complex or
recurrent hernias. This will allow for a shared decision process to occur
between the patient, family, and care team.
Preoperative Workup
At the initial surgical consultation, a complete history and physical
examination should be performed. This will elicit the potential complexity
of the hernia repair and expose patient risk factors for perioperative
morbidity and mortality. Also, a clear understanding of symptoms caused
276
S. Philipp
by the hernia and the impact on quality of life can be established. Risks
and bene fi ts of surgery can then be discussed and identi fi ed risk factors
worked up further with noninvasive cardiac studies, laboratory testing,
and radiographic imaging.
Cardiac Testing
Patients with cardiac risk factors and those undergoing intermediate
and high risk surgical procedures based on ACC/AHA guidelines should
be sent for noninvasive cardiac testing. Patients with severe or unstable
heart disease should have elective surgery delayed until appropriate
cardiac intervention is performed.
Laboratory Studies
Blood testing should be performed based on identi fi able risk factors
found during initial history and physical examination. Complete blood
count and coagulation factors should be tested to evaluate for occult
infections, anemia, platelet disorders, and coagulopathy. Chemistry
testing should be performed to evaluate for hepatic and renal disease,
electrolyte imbalance, hyperglycemia, and thyroid function. A
hemoglobin A1c can evaluate long-term glycemic control. Urine cotinine
testing is useful for evaluating compliance with smoking cessation.
Radiographic Imaging
Radiographic imaging should not be routinely used for diagnosis and
planning of surgical repair of hernias. Pelvic ultrasound can sometimes
be useful in the diagnosis of occult inguinal hernia when patient history
is convincing for a hernia, but physical examination is unrevealing.
Abdominopelvic computed tomography is a useful adjunct in certain
patient populations, particularly those with recurrent and/or complex
hernias, multiple hernias, hernias in challenging or uncommon locations,
and when physical examination is limited or unrevealing.
277
23. Patient Comorbidities Complicating a Hernia Repair
Informed Consent
Appropriately preparing a patient for their upcoming hernia surgery
is such a complex and important task that it deserves its own section to
adequately discuss it (Tables 23.1 and 23.2 ). Most patients will come to
this discussion with some preconceived notions, either from research,
experience shared from a friend or relative, or personal experience. In
general, hernia surgery is regarded as routine, low-risk, and easy from
which to recover. However, hernias come in all shapes and sizes and
carry signi fi cantly different degrees of risk and expected outcomes. It is
important to have a detailed discussion regarding indications for surgery,
preoperative risk factors, surgical plans and contingencies, operative and
postoperative risks, and realistic expectations for recovery and long-term
outcome. It is equally important to involve the patient and their
preferences and wishes in the surgical planning as much as possible.
Perioperative Considerations
The identity of the patient should be con fi rmed, and informed consent
should be reviewed with all questions answered prior to anesthesia
induction. NPO status and medications should be con fi rmed. If a bowel
Table 23.1. Informed consent for ventral hernia repair.
Bleeding
Infection
Visceral organ injury
Intestinal injury
Enterocutaneous fi stula
Nerve damage
Chronic pain
Seroma
Hernia recurrence
Myocardial infarction
Stroke
Pulmonary failure
Ventilator dependence
Renal failure
Deep venous thrombosis
Pulmonary embolism
Need for further treatments and/or operations
278
S. Philipp
prep has been performed, then appropriate completion should be veri fi ed.
Preoperative studies and labs should be reviewed. Type and crossmatch
should be sent and blood products con fi rmed available for selected
patients. For diabetic patients, a blood glucose level should be checked
and insulin treatment given if necessary. For patients who recently quit
smoking, a urine cotinine test should be performed to verify compliance.
Preoperative subcutaneous heparin should be administered, and lower
extremity intermittent pneumatic compression devices should be initiated
based on the 2008 Chest guidelines for DVT prophylaxis [ 14 ] .
Perioperative antibiotics should be initiated within 1 h of surgical start
time. Prior to moving the patient to the operating room, the surgical plan,
perioperative considerations, and potential concerns should be discussed
with the anesthesiologist. For large abdominal wall reconstructions,
preoperative placement of an epidural catheter for pain management
after surgery should be considered. If need for an ICU bed is anticipated,
this should be con fi rmed prior to surgery. Also, necessary suture and
mesh materials should be con fi rmed available.
Intraoperative considerations include surgical technique and choice of
suture and mesh materials. This will be discussed in detail throughout
other sections of this text. Regardless of the operation performed, an
Table 23.2. Informed consent for inguinal hernia repair.
Bleeding
Infection
Visceral organ injury
Bladder injury
Intestinal injury
Injury to vas deferens
Injury to testicular vasculature
Ischemic orchitis
Nerve damage
Chronic pain
Seroma
Hernia recurrence
Myocardial infarction
Stroke
Pulmonary failure
Ventilator dependence
Renal failure
Deep venous thrombosis
Pulmonary embolism
Need for further treatments and/or operations
279
23. Patient Comorbidities Complicating a Hernia Repair
emphasis on good surgical technique, strict adherence to sterility,
meticulous hemostasis, and avoidance of complications is ideal. Changing
the surgical plan and/or asking for assistance should never be considered
a failure if done in the best interest of the patient. It is necessary to
maintain good communication with the anesthesiologist and surgical
team, keeping them informed of progress and problems when they arise.
Whenever possible, local anesthetic should be used to decrease
intraoperative anesthetic requirements and initial postoperative narcotic
requirements. Antibiotics should be redosed during surgery as necessary.
Postoperative Planning
The vast majority of umbilical hernia, inguinal hernia, and small
ventral hernia repairs are performed in the outpatient setting. Patients are
discharged from the recovery room after appropriate criteria are met. For
most ventral hernia repairs patients, an abdominal binder is placed to be
worn for comfort as needed. Activity is restricted based on the procedure
performed and the preference of the surgeon. In general, laparoscopic
procedures allow for a faster return to full activity than open procedures.
Oral narcotics should be given for expected incisional pain and stool
softeners for constipation. Patients with urinary retention should have a
Foley catheter placed and be started on alpha blockers. The catheter can
be removed and a postvoid residual checked in 1 week. Persistent urinary
retention or an elevated postvoid residual should prompt referral to a
urologist for further evaluation. Patients should be evaluated once at
1–4 weeks after surgery to verify successful hernia repair and appropriate
patient recovery.
Those patients with signi fi cant comorbidities and/or complex hernia
repairs will require inpatient admission. Close monitoring for
complications and initiation of preventive measures are essential.
Abdominal Compartment Syndrome
Abdominal distension, pulmonary failure, and oliguria are
manifestations of abdominal compartment syndrome and should prompt
measurement of bladder pressure. Routine bladder pressures should be
measured for patients at high risk for abdominal compartment syndrome.
280
S. Philipp
Surgical abdominal decompression should be considered in patients with
bladder pressures above 25 mmHg and associated end-organ failure.
Atelectasis/Pneumonia
Preventative measures for atelectasis and pneumonia include early
initiation of incentive spirometry, keeping the head of the bed elevated
above 30°, early patient mobilization, and use of chlorhexidine
mouthwash [ 15 ] .
Deep Venous Thrombosis and Pulmonary Embolism
Preoperative administration of heparin, intraoperative use of
intermittent pneumatic compression devices, and post-op need for
unfractionated heparin or low molecular weight heparin are based on 2008
chest guidelines for DVT prophylaxis [ 14 ] . All patients should be
mobilized quickly and physical therapist assistance used early as needed
by the patient.
Enterotomy
A missed or delayed enterotomy is the number one cause for
perioperative mortality after ventral hernia repair [ 16 ] . Making this
diagnosis requires a high index of suspicion and demands prompt surgical
intervention.
Paralytic Ileus
This is relatively common after complex hernia repairs that involve
extensive intra-abdominal adhesiolysis and can be a source of frustration
for patients. Several things can be done to facilitate the return of bowel
function including frequent ambulation, adequate intravenous fl uid
hydration, aggressive correction of electrolyte imbalance, and use of
nonnarcotic medications for pain control, among others. Alvimopan, a
selective opioid receptor antagonist, has been shown to reduce hospital
length of stay and time to GI recovery after abdominal surgery and may
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23. Patient Comorbidities Complicating a Hernia Repair
be of bene fi t in post-op hernia patients although this has not been studied
[ 17 ] . A paralytic ileus lasting longer than 7 days should prompt further
workup to rule out other causes such as a mechanical bowel obstruction
or intra-abdominal source of infection.
Pain Management
Selected patients should be offered an epidural catheter that can be
placed prior to surgery and then used afterward for pain management.
Intraoperative usage of local anesthetic should be liberal. Local anesthetic
infusion pumps are available and can provide effective pain relief when
used by experienced surgeons in selected situations. Otherwise, pain should
be controlled using narcotics and nonsteroidal anti-in fl ammatory drugs.
Summary
Abdominal wall hernias are found in all patient populations and
involve a wide spectrum of complexity. An understanding of how
comorbid conditions will impact the surgical repair of hernias is critical
to achieving successful outcomes. This includes thorough identi fi cation
of comorbid conditions and other potential risk factors followed by
medical optimization and maximal risk reduction prior to surgery. It also
includes meticulous preparation including consideration of surgical
technique, availability of materials, and understanding of institutional
capabilities, good intraoperative communication and surgical judgment,
and optimal postoperative prophylaxis and identi fi cation of complications.
Most important is the emphasis on good communication with the patient.
It is critical to have a thorough discussion of the risks and bene fi ts of
surgery and set realistic expectations for recovery and long-term results.
References
1. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias:
nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238(3):391–9.
2. Tsereteli Z, Pryor BA, Heniford BT, Park A, Voeller G, Ramshaw BJ. Laparoscopic
ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 2008;12(3):233–8.