This surgery is a procedure that is performed to strengthen the muscles and tissues of the abdominal wall, which have been damaged by herniation. The operation of an abdominal hernia is used to correct body segment protrudes through an opening or weak area of the abdominal muscles. Often the use of meshes is needed to help to strengthen the hernia area in order to prevent recurrences. These meshes are usually made of monofilament of polypropylene, which is integrated in the intestinal walls of the patient, so that human tissue cells are integrated between the fibers to form a strong tissue. There are other materials that are also used in our services.
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There is also the possibility of accepting book reviews of recent publications related to General and Digestive Surgery. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published.
Read more. SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Evisceration is another important problem, with a lower rate 2.
Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings.. This narrative review intends to provide an update on incisional hernia and evisceration prevention.
We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it.
Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.. Incisional hernias IH are one of the most common pathologies treated by the General Surgery Department. In the United States, for example, two million laparotomies are performed each year, 2 and more than incisional hernias are treated surgically.
In addition, a significant percentage can present serious complications, such as incarceration, strangulation or bowel obstruction that will require urgent surgery. Evisceration is another serious problem that can arise after laparotomy, with an approximate incidence of 2. All the incisions that are used to access the abdominal cavity, whether midline laparotomies or incisions to introduce trocars in laparoscopic approaches, can potentially develop IH.
In addition, there are well-known risk factors 4 that increase the chances of the patient having an IH, such as obesity, urgent surgery, smoking, abdominal aortic aneurysms or the appearance of postoperative wound infection. For all these reasons, the prevention of IH has emerged as a fundamental objective for correct patient treatment due to the improved quality of life and cost savings that it would entail.
The objective of this study was to provide a narrative review about the prevention of IH and evisceration. First, we describe the aspects related with correct closure of the abdominal wall, followed by the possibility of using prosthetic reinforcement in those patients or cases requiring it. Special cases of incisional hernias, such as those caused after the insertion of laparoscopy trocars or those secondary to the completion of a stoma, are also contemplated in this paper.
The recommendations made based on these studies established that correct closure should be done with continuous suture, in a single plane and with slow-absorption suture material. The next evolution in abdominal wall closure was the change in the size of the suture and the distance between stitches.
Despite all the above, there are still questions on how to proceed with the closure of abdominal wall incisions, such as closing the laparotomy in emergency situations, in contaminated environments, how to close non-midline laparotomies, or closure in difficult situations or in patients at risk.
In short, during abdominal wall closure after midline laparotomy, the amount of thread used should be calculated according to the length of the incision measured, ensuring a ratio of at least The small-stitch technique with small continuous monofilament sutures in a single aponeurotic plane may be recommendable in the closure of elective median laparotomy. Despite correct closure of the abdominal wall following the recommendations outlined above, a systematic review has published an IH rate of To avoid high IH rates in spite of the appropriate closure of the incision, and especially in high-risk patients, prosthetic reinforcement of the abdominal wall closure has been described.
We reviewed the evidence published about the use of prophylactic mesh in various types of laparotomies excluding prophylactic mesh in parastomal hernias and the incidence of complications for the different degrees of contamination of the surgical wound according to the classification by the Centers for Disease Control and Prevention CDC. A total of 30 studies were identified, including 14 randomized clinical trials, 20—33 8 case-control studies 34—41 and 8 cohort studies or case series. Table 1 presents a summary of all available data specifically related to the incidence of wound infections and prosthesis-related complications.
In addition, the overall IH rate results were extracted. In the studies analyzed, several prophylactic meshes were used permanent synthetic, absorbable synthetic or biological , and the position in which they are placed also varied onlay or retromuscular. The evidence analyzed indicates that the procedure can be safe and effective both in clean and in clean-contaminated surgeries.
There is not enough evidence available about safety in contaminated or dirty surgeries. The fundamental limitation of this analysis is the quality of the included studies, which varies greatly as the studies range from large multicenter randomized studies to small case series, as well as the diversity of mesh used and their placement positions.
Despite the limitations of this review, it appears that prophylactic mesh patches could potentially be used to prevent IH in clean or clean-contaminated surgery.
Most studies have used permanent synthetic mesh, while some studies have used absorbable synthetic or biological mesh. The position of the mesh will probably depend on the preference of each surgeon. To identify in which group of patients at risk a prophylactic mesh should be recommended, further studies are necessary. Fischer et al. These risk models could allow for the identification of patients who could benefit more from the use of prophylactic reinforcement mesh.
The incidence of parastomal hernias PH in patients with intestinal stomata may vary depending on the type of stoma in question. In addition, PH repair is associated with a high recurrence rate. After analyzing the existing literature on the use of prophylactic mesh in the construction of stomata to prevent PH 57 and with regards to terminal colostomy, most of the published studies are observational and the techniques used for the prevention of PH had a series of common characteristics: a the most common technique was an open surgical approach with retromuscular mesh positioning 58—62 ; b the majority of studies made an orifice in the center of the mesh keyhole through which the intestine is exteriorized 59—61,63 ; and c the majority used non-absorbable flat synthetic mesh.
Furthermore, in published randomized clinical trials RCT , the open surgical approach with a retromuscular mesh positioning technique is most extensively used. Several systematic reviews or meta-analyses have also been published, some quite recently, which uniformly conclude that a non-absorbable synthetic mesh in the retromuscular position reduces the incidence of PH, with no increase in morbidity related to the presence of the prosthesis.
The results show that prophylactic mesh reduces the incidence of PH without increasing complications, and since the sample size required to demonstrate the effect of the procedure has been reached, more RCT may not be needed in this context. Regarding terminal ileostomy , until now there are no primary data in the literature from studies specifically designed to evaluate the effectiveness of mesh in the prevention of PH.
There are only indirect data from studies including fundamentally patients with colostomies and a few with terminal ileostomy. As for ureteroileostomy Bricker , there is very little information available in the literature, and only two observational studies have been found with a small number of patients where it seems that the placement of a mesh for the prevention of PH may be possible and safe.
In short, there is evidence that the efficacy of non-absorbable synthetic mesh in the retromuscular position using an open approach is useful for the prevention of PH during the construction of a terminal colostomy.
However, more data are needed in the literature to definitively endorse the usefulness of preventive mesh with a laparoscopic approach, the use of mesh other than non-absorbable synthetic types, and to define the best patient profile or whether it is useful in terminal ileostomies or in ureteroileostomies Bricker.
With high TSH figures, prevention is important. Therefore, a series of factors must be considered: a Is it necessary to close all trocar sites? According to published reviews, 75 the recommendation is that all trocar orifices that are 10 mm or greater should be closed, and in children even those measuring 5 mm should be closed. Another recommendation would be to reduce the diameter of the trocars that are used as much as possible, avoiding the use of trocars larger than 5 mm, which is not always possible, using 3-mm trocars and mini-instruments.
The recommendation is to introduce the trocar through the hernia defect and repair it with mesh at the end of the operation. Bariatric surgery : In these patients, two risk factors are involved: obesity itself and the use of trocars larger than 10 mm, so their closure should be mandatory. One study 77 shows that the incidence of HT is very low with long-term follow-up, so if the trocars are placed obliquely, it would not be necessary to close them later. In any event, a prudent recommendation would be to close all the trocar orifices in bariatric surgery, and always close those orifices that are extended for the extraction of the surgical piece from the sleeve gastrectomy.
How should we close? Many devices have been used to facilitate the closing of trocar orifices. All studies highlight the need to include the aponeurosis in the closure, 78 but the importance of including or not including the peritoneum has not been established.
To date, the most appropriate suture type i. Use of prophylactic mesh. Short series 79 have published the initial experience in laparoscopic cholecystectomy, with a prophylactic mesh of titanized polypropylene introduced through the trocar and affixed with cyanoacrylate.
After a minimum follow-up of 6 months, TSH were not observed. Another author 80 described a series of patients in whom a bioabsorbable device was used in the closure of the umbilical trocar, with no complications and no appearance of TSH at the one-year follow-up.
Finally, an RCT with almost 50 patients in each arm compared the closure of the umbilical trocar with non-absorbable suture with the placement of a mesh composed of polypropylene and omega-3 acid, in an intraperitoneal position; the TSH rate was Single-port surgery seems to have a greater incidence of TSH, 81 but no specific studies have been published about how these incisions should be closed or whether preventive prostheses should be used in these cases. There are several circumstances that require the closure of a temporary stoma: reconstruction of the intestinal tract after a protective stoma ileostomy or colostomy performed in patients with low colorectal anastomosis, restoration of intestinal continuity after a terminal colostomy performed in an emergency situation for example, after acute perforated diverticulitis or reconstruction after terminal ileostomy in patients with inflammatory bowel disease.
Stoma closure surgery entails high morbidity, mainly derived from anastomotic problems, especially dehiscence, bowel obstruction, wound infection or evisceration. Another often underestimated complication is the development of a IH in the stoma closure scar. In a recent meta-analysis 82 including 34 studies with stoma closures, the overall incidence of hernia was 7.
The heterogeneity of the studies, their duration and type of follow-up clinical or radiological make it difficult to interpret and apply the results. This review demonstrates that the clinical incidence of IH after the closure of a stoma is greater than expected and may be so high as to affect one in three patients.
Another recent systematic review 83 including 16 studies and patients has confirmed these conclusions. Just as there is scientific evidence on how to close a midline laparotomy, there is no consensus 84 on which is the best method of closing the wall after the reversal of a temporary stoma: in two fascial planes or in a single plane, continuous suture or interrupted stitched, non-absorbable or long-lasting absorbable suture material.
There is only consensus regarding cutaneous closure, and tobacco pouch closure is considered to provide a lower incidence of wound infection. Common sense makes us think that if the closure with continuous suture with long-lasting absorbable or non-absorbable material following the rule is the current gold standard in the closure of midline laparotomy, then it could also be the standard in the closure of this type of incisions.
In , Liu et al. After a median follow-up of 18 months, with physical examination and abdominal CT scan, the incidence of IH in the mesh group was 6. Van Barneveld et al. In the reversion of the stoma, the defect of the fascia and the mesh was closed with continuous polypropylene suture or PDS. It is a randomized, multicenter, prospective, phase iii study that includes patients in two groups. In the experimental group, a biological mesh porcine collagen without cross-linking is used in the intraperitoneal position affixed with transfascial sutures, after which the fascia is closed over the mesh with long-term absorbable suture material.
The follow-up has an expected duration of 2 years, with clinical evaluation and CT scan after one year and only clinical evaluation after 2 years. The results are expected by the end of In , Maggiori et al. The case group included 30 consecutive patients scheduled for temporary ileostomy closure, and 64 control subjects were selected from the hospital's prospective database, matched according to age, sex, associated diseases, radiotherapy and delay between the initial surgery and stoma closure.
In all patients, closure was carried out in two planes: posterior and anterior fascia of the muscle with continuous polyglactin suture. The skin was closed in all cases with a tobacco pouch suture. This study has been used as a basis for the design of a national randomized study in France ClinicalTrials.
Patients were randomized into three groups: without mesh, with synthetic mesh and with biological mesh. The mesh prostheses were placed in retromuscular position, as in the case-control study indicated above.
In conclusion, and based on the few cases published, a preventive prosthesis in this context can reduce the incidence of IH.
The recommendations for mesh type and placement position will have to wait until results are published after the completion of the active clinical trials.
Eventraciones. Otras hernias de pared y cavidad abdominal (2012)
There is also the possibility of accepting book reviews of recent publications related to General and Digestive Surgery. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published. Read more.
Intestinal Wall Surgery
The diaphragm is the main muscle involved in ventilation and is supplied exclusively by the phrenic nerves. Congenital defects of the diaphragm muscle or phrenic nerve injury cause diaphragmatic paralysiseventration. Prognosis and treatment depend on whether involvement is unilateral or bilateral and on the patient's previous clinical status.. In addition, the diaphragm is an anatomical barrier between the thoracic and abdominal cavities and is traversed by the esophagus and important vascular and nerve structures. Abnormal dilation of the natural orifices of the diaphragm or loss of its continuity can cause abdominal structures to pass into the chest cavity, an occurrence known as diaphragmatic hernias.
Eventraciones. Otras hernias de pared y cavidad abdominal (2012)
Ignacio Hanna Musse Dr. Guy de Chauliac fue el defensor del principio: pus bonum et laudible El pus es bueno y digno de alabanza. Sin embargo, al final de las indicaciones, Chauliac explica que la base de este tratamiento es solamante la esperanza. Hay 4 puntos de reforzamiento natural de la fascia transversalis:. Tenemos entonces como elementos constitutivos imprescindibles para la existencia de una herniade :. La existencia de un saco herniario ; y.