abdominal pain/abdominal mass
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DESCRIPTIONAbdominal Pain/Abdominal Mass. Melissa L. Hughes Scott Q. Nguyen, M.D. Celia M. Divino, M.D. Department of Surgery Mount Sinai School of Medicine. HPI Mrs.Masseo. Mrs. Masseo is a 63-year-old female with PMH of HTN, DM, s/p laparotomy for peptic ulcer disease seven years ago - PowerPoint PPT Presentation
Abdominal Pain/Abdominal Mass
Melissa L. HughesScott Q. Nguyen, M.D.Celia M. Divino, M.D.
Department of SurgeryMount Sinai School of Medicine
HPI Mrs.MasseoMrs. Masseo is a 63-year-old female with PMH of HTN, DM, s/p laparotomy for peptic ulcer disease seven years agoPresents to ER with one day history of sudden, worsening abdominal pain associated with nausea, two episodes of vomiting, and abdominal distension
What other information would you want regarding this patients history?
Other Pertinent HPIPatient had noticed a bulging from her mid abdomen beneath the surgical scar for the past several months. It was not initially painful, became larger when she coughed, and would go away when she was lying down
After an acute coughing episode the morning prior to admission, patient reported that she suddenly experienced severe pain in her mid abdomen that was constant and accompanied by an increase in size of the midline bulge which did not go away when she tried to lie down
No flatus or bowel movement over the past day, several episodes of vomiting, and subjective fevers
Other Pertinent HistoryPMH: Poorly controlled HTN and DM for the past 20 yearsPSH: Appendectomy at age 35, laparotomy 7 years ago for PUD Meds: lisinopril, insulin, nexium, aspirinAllergies: NKDASocial history: 1.5 packs of cigarettes a day for the past 40 years
What would you look for on physical exam?
Physical ExamIll-appearing, obese woman in severe painBP 100/60 HR 115 Temp 38.2 C RR 24HEENT: oral mucosa dryHeart: tachycardic, regular rhythmLungs: clear to auscultation bilaterallyAbdomen: obese abdomen, healed midline laparotomy and RLQ scars, hypoactive bowel sounds, moderate distension, firm, tender softball size mass at midline scar with erythema of the overlying skin. No rebound or guarding in remaining abdomenGuaiac positive stool
What is your differential diagnosis?
Differential DiagnosisIncarcerated ventral hernia
Small/large bowel obstruction- secondary to adhesions, volvulus, neoplasm
Abdominal wall tumor
Abdominal wall abscess
What labs would you order?
30.1350 134 3.394 40201.7190 n% 89
LFTs, amylase, lipase, and coags- WNL Lab results, Mrs. Masseo
Lab FindingsPre-renal azotemia secondary to dehydration
Leukocytosis from infection/inflammatory process
What imaging would you like to obtain?
Obstructive Series Describe the X-ray findings
Xray InterpretationNo free air noted on CXRNo significant small bowel dilatation Air in right colonNo small bowel obstruction
If this patient had bowel obstruction secondary to an incarcerated loop of small bowel in the ventral hernia, then why are there no signs of small bowel obstruction on Xray?
Is there another study which may help?
CT Scan Mrs. Masseo
CT InterpretationTransverse colon incarcerated in ventral abdominal wall herniaSoft tissue stranding in subcutaneous fat around incarcerated herniaAbsence of enteric contrast past area of incarceration with collapse of left colon consistent with complete large bowel obstruction
What would be your next step in management?
Hospital CourseImmediate resuscitation with IV fluids, foley catheter, NG tube decompression and pre-op antibioticsPatient taken to the OR for incarcerated hernia with suspected strangulated bowelExploratory laparotomy performed using previous midline incisionFound to have ischemic loop of transverse colon twisted upon itself, herniating through a 4cm abdominal wall defect Segment of ischemic bowel was resected and primary anastomosis performedHernia repaired primarily, skin was left open
Hospital CoursePatient did well post-operatively without complicationsPOD #4: regained bowel functionPOD #6: tolerated normal dietPOD#7: discharged home
What is the problem with repairing this patients hernia primarily? Would you want to use mesh in this situation?
Primary repair of Ventral (Incisional) Hernia Recurrence of a ventral hernia is a common problem in primary suture repair, whereas repair with prosthetic mesh often has lower recurrence ratesHowever, in a patient with strangulated, ischemic bowel who undergoes a bowel resection, inserting mesh into a contaminated field increases risk of infection of the mesh and ultimate need for reoperation and removal
Follow-upPatient seen at follow-up appointment 6 months later and was found to have another reducible hernia through the same 4cm abdominal wall defectPatient denied any abdominal pain, distension, nausea, vomiting, or fevers
What would you do next to help this patient?
Discuss treatment options for repair of recurrent incisional herniasDiscuss pre-operative preparation
Follow-upPatient taken back to the OR for elective ventral hernia repair Open hernia repair performed using non-absorbable mesh in an under-lay fashionPatient continues to do well two years after elective repair without any signs or symptoms of recurrence
Incisional Hernia DiscussionHernias that occur at a prior abdominal incision site (includes post laparotomy hernias, parastomal hernias, and trocar site hernias)Incisional hernias reported in up to 20% of patients undergoing laparotomy with modern rates ranging from 2-11%Approximately 100,000 ventral incisional hernia repairs performed each year in U.S.Most present within 12 months post-laparotomy although as many as 1/3 may present 5-10 years later
What are the risk factors for developing an incisional hernia?
Risk FactorsPatient-related factors: advanced age, malnutrition, diabetes mellitus, cigarette smoking, corticosteroids, conditions that increase intra-abdominal pressure like obesity ascites, or chronic cough
Surgery-related factors: wound or intraabdominal infection, closure of abdomen under tension, type and location of incision (vertical midline incision more prone to incisional hernia than transverse), lack of mesh overlap at hernia edges (bridge technique)
Clinical Manifestations and DiagnosisBulge in abdominal wall at or near surgical scarDiscomfort aggravated by coughing or strainingEnlarges over time leading to pain, bowel obstruction, incarceration, and strangulationIn large hernias, the skin may present with ischemic or pressure necrosis resulting in ulcerationUsually easy to identify on exam, with palpable edges of fascial defect In obese patients with suspected incisional hernias the surgeon should have a low threshold for obtaining a CT abdomen as the clinical exam is very unreliable
TreatmentTreatment includes two general types of operative repair: primary suture repair and prosthetic mesh repair Recurrence rates for non-prosthetic repair can be as high as 50% or more, whereas mesh repair is associated with significantly lower recurrence rates
Primary RepairUsually performed for hernia defects less than 4 cm in diameter, with strong, viable surrounding tissue using an interrupted layer of nonabsorbable suturesSome studies have suggested that even these small hernias may have a substantially lower recurrence rate after mesh repairSeparation of components is a technique that utilizes the bodys own tissues for hernia repair, avoids the use of a foreign body, and in experienced hands may have very good results
Prosthetic RepairFor large hernias, or hernias associated with multiple small defects, mesh should be placed by open or laparoscopic approachMesh provides tension-free repair by avoiding the recreation of tension by fascial apposition. In large hernias with loss of domain , fascial apposition may not even be possible.Much improved recurrence rates over primary repair
Many different prosthetic materials available today for hernia repair but limited evidence and comparative studies existBioabsorbable meshes have become popular and may be used in an infected field but should not be regarded as permanent hernia repair as high rates of recurrence/ dilatation have recently been describedMany techniques for mesh placement: (ex) Rives-Stoppa repair where mesh is placed in retrorectus space, laparoscopic repair with mesh placement intraabdominally behind the rectus and peritoneum, open in-lay, on-lay and under-lay mesh repairs. Technique may be paramount in recurrence ratesProsthetic Repair
ComplicationsRecurrence: As high as 30-50% in primary suture repair, 5-35% in open mesh repair, and 0-11% in laparoscopic mesh repairWound infections are more common after open repair compared to laparoscopic Mesh infection often necessitates removal of mesh but can occasionally be treated with IV antibiotics and local wound careErosion of mesh into bowel with development of enterocutaneous fistulasBowel obstruction/ileus
References Feldman LS, et al. Laparoscopic Hernia Repair. ACS Surgery: Principles and Practice. Chapter 5, Section 28. 2003 Fitzgibbons RF, et al. Open Hernia Repair. ACS Surgery: Principles and Practice. Chapter 5, Section 27. 2003 Townsend CM. Sabiston Textbook of Surgery. 17th edition Zinner, MJ, et al. Postoperative Ventral Wall (Incisional) Hernia. Maingots Abdominal Operations. Chapter 5. Hernias. 11th edition
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