Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (21 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Much of what has been mentioned above is applicable to hernia repair in the emergency situation. However, there are a few dilemmas that occur more frequently in the emergency setting. Patients who present as an emergency but have no bowel compromise can be treated as per elective hernia surgery. When bowel is compromised, especially when there has been significant contamination, current opinion is that synthetic mesh should not be used. However, there is little in the way of evidence apart from anecdote to support such a view and this view has been challenged.
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The case for biological mesh in such scenarios is also lacking in evidence.
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For those who support the laparoscopic approach, it is not unreasonable to offer this in the emergency setting and laparoscope the patient with an irreducible inguinal hernia. If the bowel can be reduced and is viable, then convert the operation to a TEP and place mesh as usual. If the bowel is compromised, then resect the bowel through a small incision and return 6 weeks later for a TEP. In the emergency incisional/ventral hernia setting, if the hernia is large, then proceed directly to open sublay mesh repair. If the hernia is smaller, then laparoscopy and intra-abdominal mesh are appropriate if there is no bowel compromise. If there is bowel ischaemia, then convert to the open sublay repair. The use of mesh in the sublay space in the emergency setting should not be associated with an increase in mesh infection as it lies external to the peritoneal cavity, but clearly each case will need to be assessed individually.
Emergency hernia surgery remains a high-risk surgical procedure, with the main risk factor for postoperative mortality being infarcted bowel.
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Such operations should not be left to junior members of the surgical and anaesthetic teams. Appropriate resuscitation, followed by timely and appropriate surgery, may save lives. Occasionally, the techniques of damage limitation surgery (see
Chapter 13
) may be appropriate.
This is a hernia with an increasing incidence associated with the increase in laparoscopic surgery. Insertion of larger ports through the midline as opposed to more laterally appears to be a significant risk factor. This is especially true in the presence of a divarification of the recti or an unrecognised umbilical hernia. There is little evidence to support closure of the fascia except when a cut-down is performed for the first port. The use of dilating rather than cutting trocar tips may reduce the incidence of port-site hernia formation.
In general, elective hernia surgery to the groin and ventral regions does not require antibiotic prophylaxis.
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However, as the risk of bowel injury is always present in incisional hernia surgery, it would be reasonable to give routine antibiotic prophylaxis for such surgery. Patients at increased risk of infection, including the immunocompromised, skin conditions with higher bacterial carriage such as psoriasis and in the emergency setting, all merit antibiotic prophylaxis.
All theatres have bacteria (called colony-forming units) in the circulating theatre air. It therefore makes sense to open the mesh just before it is required during the operation. Changing to fresh gloves before the handling of the mesh, minimising mesh contact with the skin and inserting the mesh deep to the subcutaneous tissues may all help reduce the risk of mesh contamination. The author uses a gentamicin solution (240 mg gentamicin in 250 mL normal saline) to irrigate larger meshes following insertion, although there is no evidence-based medicine to support this manoeuvre. Methicillin-resistant
Staphylococcus aureus
(MRSA) bacteria have been found on mesh several years after insertion, so prophylaxis to MRSA is appropriate if a previous repair has been complicated by MRSA infection.
The topic of prophylactic mesh insertion to minimise subsequent hernia formation in high-risk groups of patients remains controversial. One study reduced the incidence of incisional hernia following open gastric bypass surgery from 21% to 0% by the prophylactic insertion of a polypropylene mesh in the sublay position.
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Another study reduced the incidence of parastomal hernia following permanent end colostomy from 50% to 5% by the prophylactic insertion of a polypropylene mesh in the sublay position at 2 years' follow-up.
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At 5 years' the rates were 81% and 13%, respectively.
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Both studies have small patient numbers, but no increase in morbidity was noted in the prophylactic mesh group. It is likely that prophylactic mesh to minimise subsequent hernia formation will become more mainstream practice. This may be supported by preoperative collagen type I/III ratio typing to perhaps select patients more at risk. This concept of collagen disease is important, and introduces the notion that hernia repair of any type will fail if the patient lives long enough. It is true that some surgeons' repairs last longer than others, so technical factors remain important, and mesh repairs at any time point are more likely to be intact compared to a suture repair.
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(Re-operation rates are a surrogate for recurrence rates, although re-operation will underestimate the true recurrence rate.) However, a hernia repair at present is a patch-up job, and will probably fail eventually (if the patient lives long enough). Nevertheless, randomised trials in patients at high risk of developing incisional hernia are ongoing.
In general, an infected mesh has to be removed or exposed to the surface. If the mesh is lying in a pool of pus with no adherence to the patient, then the only option is removal of the mesh. If the mesh is partly embedded in tissue, then if there is adequate drainage through an open wound, many infected meshes will slowly granulate over and remain sound. However, sometimes chronic sinuses will develop and the only option is excision of these along with as much of the visible mesh as possible. Not all patients who require mesh removal will develop a hernia recurrence, although the majority probably will at some stage in the future.
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It is the author's opinion that it is best to remove as much of the mesh foreign body as possible, control the sepsis and return at a later date for further repair. The use of biological mesh in a contaminated field is rarely indicated. The use of vacuum-assisted dressing to control the fluid exudates from the wound may aid wound care in such patients.
Key points
Herniorrhaphy is one of the commonest operations performed.
Techniques advanced considerably during the 1990s.
The use of prosthetic mesh should now be considered for the repair of all hernias.
The laparoscopic approach may be more appropriate than a traditional open approach.
Recurrent hernias may be best managed in specialist centres or by surgeons with a specialist interest in hernia surgery who are technically competent to perform both open and laparoscopic procedures.
A multidisciplinary approach, including plastic surgeons, may be appropriate for complex, multiply recurrent hernias.
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