Approach to the Hernia Patient
• Individualized approach
• Complete History and Physical
• CT Scan – Recurrent hernia
– Atypical location
– Obesity
• Old operative notes whenever possible
• Routine laboratory studies, nutritional panel
Risk factors for Hernias
• Obesity • Diabetes Mellitus • Smoking
• COPD • Advanced age • Malnutrition
• Immunosuppression, steroids • Radiation Therapy • Connective tissue Disorders
Obesity and Abd Pressure
• 45 morbidly obese (BMI 55)
– 12mm (+ 0.8) Hg in obese
– 0mm (+ 2) Hg in controls
Underweight < 19
Normal 19 - 25
Overweight 26 - 29
Obese Class I 30 - 35
Obese Class II 35 - 39.9
Morbid Obesity > 40
Super Obesity > 50
BMI = Weight kg/Height m2
BMI 40 = approximately 100 lbs above ideal weight
Definition of Obesity
66%
as of
2004!!
Preoperative Goals: Patient Discussion
• Set realistic expectations:
– Goals of repair
– Timing of repair
– Understanding magnitude of procedure
– Complications
– Recovery
Preoperative Goals
• Weight Loss – Set specific goals
– Bariatric surgery first if necessary
• Smoking cessation (ideally ≥ 4 weeks)
• Heal chronic wounds
• Increase physical activity
• Optimize nutritional status
• Optimize cardiopulmonary status
Surgical Planning
• Key concepts:
– Tension-free repair • MUST reduce abdominal pressure
– Mesh UNDERLAY • MOST effective placement strategy
– Minimally invasive approach • MINIMIZES surgical dissection
• MAXIMIZES visualization and recovery
Operative Technique • Access
• Adhesiolysis – Sharp dissection
– Energy source only if unavoidable – accept some bleeding
– Direct visualization
• Assess and measure defect – Techniques for doing this?
• Mesh/prosthetic preparation
• Mesh placement – Overlap
– Tacks, sutures, how many sutures?
Operative Technique: Close Defects?
Overall Mesh only 4.8% Primary repair with mesh 3% Recurrent hernia Mesh only 10.5% Primary repair with mesh 4.8%
Banerjee, et al. Surg Endosc (2012) 26:1264–1268