Sabiston Textbook of

Surgery, 18
th
Ed
Erik Peltz, D.O.
December 9
th
, 2010
University of Colorado Health Science Center
Department of surgery
Hernias
Background
Hernia: abnormal protrusion of an organ or
tissue through a defect in its surrounding walls.
Reducible: Contents can be replaced
Incarcerated: Cannot
Strangulated: Compromised blood supply
External vs Internal vs Interparietal
Richters hernia
Background
Hernia:
5% of patients will develop an abd wall hernia
75% inguinal region
15 20% incisional
10% umbilical and epigastric
5% femoral
Background
Groin hernias M:F 25:1 Indirect:Direct 2:1
Femoral F:M 10:1
Umbilical F:M 2:1
Inguinal vs Femoral hernia ?
Inguinal are more common than femoral hernias in
both M, F
10% of females and 50% of males with femoral hernia will
develop and inguinal hernia
Background
Indirect Inguinal hernia Which side is more
common?
More common on right
Slower descent of right teste
Delayed atrophy of the right processus vaginalis
Femoral Hernia
More common of right
Tamponade of sigmoid colon protecting Left?
15 20% rate of incarceration.
Mandate operative repair when diagnoses
Anatomy
Anatomy
Inguinal Canal
Contains the spermatic cord / round ligament of the uterus
Spermatic cord
Cremasteric muscle inferior extension of internal oblique
Testicular artery (aorta), Veins (left renal, right IVC)
Genital branch genitofemoral nerve
Vas deferens
Lymphatics
Processus vaginalis
Bounderies
Inferior Epigastrics
Superior Lateral border
Rectus Sheath
Medial border
Inguinal Ligament
Inferior border
Hesselbachs triangle
direct Hernia
indirect Hernia
Associated Nerves
Iliohypogastric (L1) suprapubic / inguinal sensation
Beneath the interal obl. at the ASIS
Penetrate I.O. and course superior / medial
Ilioinguinal (L1) Inguinal / scrotal / proximal thigh
Beneath the interal obl. At the ASIS
Penetrates I.O. and courses superior / medial overlying cord
Genital branch (L1 L2), genitofemoral
Courses with the cremaster fibers in the spermatic cord
Cremaster motor
Scrotal sensation
Femoral Canal
Boundaries
Iliopubic tract anteriorly
Coopers ligament posteriorly
Femoral vein laterally
Differential Diagnosis
Inguinal hernia
Femoral hernia
Adenitis
Varicocele
Ectopic teste
Lipoma
Hematoma
Sebaceous cyst
Hidradenitis
Lymphoma
Metastatic neoplasm
Epididymitis
Testicular torsion
Vascular aneurysm /
Pseudoaneurysm
Diagnosis
Hx / PE
Supine and Standing
Valsalva
Invagination of scrotum to inspect canal
Inguinal adenopathy?
Hx CA?
Rectal Exam? Colonoscopy?
Bulge below inguinal ligament Femoral Hernia
Comorbidities: Pulmonary, Cirrhotics, renal failure /
dialysis, Constipation / GI / Colon CA?
Diagnosis
Imaging:
Ultrasound: sensitive and specific
CT
Laparoscopy
Non-operative management
Fitzgibbons et al., JAMA 2006
700 pts randomizes to non-op vs operative repair
25% non-op pts crossed over (pain / enlargement)
Incarceration with non-op 0.03%
No difference in operative outcome with watchful
waiting (SSI, OR time, Recurrence Rates)
Operative management
Tissue Repair
High recurrence rates largely replaced by mesh repairs
Remain useful / important in certain situation
Strangulated hernias / bowel resection / infection
Iliopubic Tract Repair
Shouldice
Bassini
McVay
Tissue Repair
Iliopubic Tract Repair
Approximates the
transversus abdominis /
conjoint tendon to the
iliopubic tract.
Tissue Repair
Bassini Repair
Single layer repair
T. Abdominis / IO /
conjoint tendon to the
inguinal ligament
Tissue Repair
Shouldice Repair
Multi-layer repair
T. Abdominis incised
Overlap T.A.
Free edge of T.A. Iliopubic
tract.
2
nd
deep layer of interal
oblique / T.Abdominis to
inguinal ligament
May incorporate relaxing
incision
Low recurrence rate for
tissue repair (2%)
McVay Tissue Repair
McVay Repair
Multi-layer
Very useful in incarcerated or strangulated femoral hernias.
Approximates Transversus Abdominis to Coopers Ligament
(postero-medial aspect of femoral canal)
Relaxing incision in posterior aspect of the anterior rectus
sheath then allows layered closure of internal oblique to
inguinal ligament tension free fashion.
McVay Tissue Repair
Mesh Repair
Lichtenstein
Tension is the pricinpal cause of recurrence
Tension Free Mesh Repair
Lichtenstein
Tension is the pricinpal cause of recurrence mesh placed to
reinforce the inguinal floor / Internal ring
May be sutured to conjoint / internal oblique and iliopubic tract
Results:
Several Randomized Controlled Trials
Recurrence 0% - 3.5%
Critics note short follow-up (1-3 yrs) in many of these
trials.
Rate is better than 5 15% reported for many primary tissue
repairs.
Preperitoneal Repair
Pre-peritoneal Repair
Involves initial incision 2cm cephalad to the internal
ring.
Dissection to the preperitoneal plane through the
anterior rectus muscles
Both primary and mesh repairs described.
Very useful open approach for:
Recurrent Hernias
Sliding Hernias
Stangulated Hernias
Femoral Hernias
Laparoscopic Inguinal Repair
Trans-abdominal Preperitoneal (TAPP)
Totally Extraperitoneal
Very useful for bilateral hernias / recurrence
Recurrence Rates from RCT 0 10%
Veterans Admin RCT
TEP vs Lichtenstein
Recurrence 10% vs 5%
Surgeon experience with technique questioned
Special Considerations
Sliding Hernia
Internal organ comprises a portion of the wall of the
hernia sac. (Colon or Bladder)
Careful identification before injury to organ
Recurrent
McVay, open preperitoneal, laparoscopic
Stangulated
Open preperitoneal
Allows single incision evaluation, resection and
repair of hernia
Complications
SSI
1 2% open, less with laparoscopic
No abx necessary for elective repair
Including placement of mesh
Abx for:
ASA > 3, comorbidities, strangulation, etc
Complications
Nerve Injury
Traction, electocautery, transection, entrapment
Ilioinguinal, Iliohypogastric, Genitofemoral
Lateral femoral cutaneous (laparoscopic)
Chronic pain has surpassed recurrence as the
leading postop complication (29 76%)
Complications
Ischemic Orchitis
Thrombosis of pampiniformplexus veins
Tender / swollen teste POD 2 5
Continues for 6 12 wks
Test atrophys
Complications
Recurrence:
1 3% tension free and laparoscopic repairs
Most commonly recur within 2 yrs
Shouldice has the lowest reported recurrence rate for tissue
repairs 2%
Umbilical Hernia
Congenital in infants
Most close by 2yoa. Repair if persist after 5yoa.
Adults acquired
Obesity, ascites, pregnancy, abdominal distension
Primary Repair vest over pants
10 30% recurrence rate
< 3 cm may primarily repair with interupted suture
> 3 cm mesh under lay, overlay, +/- primary closure
Epigastric Hernia
2 3 times more common in men
Often incarceration of preperitoneal fat
Pain
20% multiple
80% off of the midline
Repair similar to umbilical hernia
Surgical Site Infections
Causes and Risk Factors
Bacterias Fault (Microorganism)
Surgeons Fault (Local Wound Factors)
Patients Fault (Patient Factors)
BACTERIA LOCAL WOUND PATIENT
Remote site infection Surgical Technique Age
Long-term care facility Hematoma / seroma Immunosuppression
Recent hospitalization Necrosis Steroids
Duration of procedure Sutures Malignancy
Wound class Drains Obesity
ICU Patient Foreign bodies Diabetes / Glucose Control
Previous Abx Malnutrition
Preoperative shaving Comorbidities
Bacterial #, virulence, resistance Transfusions
Cigarette
Oxygen Delivery
Temperature
Surgical Site Infections
Preventative Measures for SSI
Timing of action Bacteria Local Patient
Preoperative -Shorten Preop Stay
-Antiseptic Shower
-Hair Clippers
-Postpone Surgery or
treat remote infection
-Apporpriate Prophylaxis
-Bowel Prep?
-Hair Clippers -Optimize Nutrition
-Pre-operative Warming
-Strict Glucose Control
(80 110)
-Smoking Cessation
Intraoperative -Asepsis
-Antisepsis
-Control Spillage
-Supplemental O2 (80%)
-Intra-operative Warming
-Fluid Resuscitation
-Strict Glucose Control
Postoperative -DSG48 72 hrs
-Early Drain Removal
-Avoid Postop Bacteremia
-Early Enteral Nutrition
(EAST)
-Supplemental O2
-Strict Glucose Control
-Surveillence Programs
Bacterias Fault
Asepsis and Antisepsis Practices
Chlorhexidine Shower
No reduction in SSI. Do reduce bacterial colony count.
CDC recommendation
Cardiac, Vascular, Prosthetic Procedures
No shave
Germicidal Skin prep
Surgical scrub
Sterile technique
Gowns/masks/hats/gloves/OR FOOT TRAFFIC
Antimicrobial Prophylaxis
Enteral (Abx bowel prep)
Non-absorbable antibiotics to suppress both aerobic
and anaerobic intestinal bacteria.
Neomycin + Erythromycin at 19, 18 and 9 hours before
surgery. (Nichols Prep)
Effect of Preoperative Neomycin-Erythromycin Intestinal
Preparation on the Incidence of Infectious Complications
Following Colon Surgery. Nichols, RL et al. Ann Surg. 1973;
178(4): 453-462.
Meta-analyses have recently shown no benefit
over IV Abx and when combined with mechanical
prep there is a trend towards increased anastomotic
leaks.
Antimicrobial Prophylaxis
Intravenous
Clean Cases
Not indicated for low-risk, straightforward clean
procedures with no obvious bacterial contamination or
insertion of a foreign body.
All others: Abx appropriate to anticipated flora
should be given within one hour of incision and re-
dosed at 1 2 half lives for longer cases.
Antimicrobial Prophylaxis
Intravenous
No anticipated entry into colon / distal small bowel
Ancef
Clindamycin (cephalosporin allergy)
Potential SB / Colon
Must cover for obligate anaerobic bacteria (Bacteroides)
Cefotetan, Cefoxitin (shorter T )
Antimicrobial Prophylaxis
Intravenous
Concern for MRSA (IVDA, Institutionalized, NH,
recent hospitalization)
Vanc
Patients Allergic to Cephalosporins with planned
bowel surgery
Aminoglycoside or Flouroquinolone + Clinda or Flagyl
Aztreonam+ Clinda or Flagyl
Zosyn, Ertapenem, etc
Antimicrobial Prophylaxis
Common flora
Biliary Tract: Chronic Cholecystitis: < 1% SSI
Gram Negative GramPositive Anaerobes Fungi
Klebsiella
Escherichia coli
Enterobacter
Pseudomonas
Citrobacter
Proteus
Enterococcus
Streptococcus
Bacteroides
Clostridium
Candida
Open Chole Lap Chole OpenBiliary ERCP
Ancef Low risk NONE
High risk Ancef
Unasyn,
Carbepenems,
Cipro +Flagyl,
Cefotetan,
Cefotaxime,
Ceftriaxone
Lowrisk None
High risk
Unasyn,
Carbepenems,
Cipro +Flagyl,
Cefepime
Antimicrobial Prophylaxis
Common flora
Appendicitis:
Must cover aerobic and anaerobic bacteria
Cefoxitin, Cefotetan
Levo + Flagyl
Zosyn ?, Ertapenem?
Aerobic /
Facultative
Anaerobes
Anaerobic
Escherichia coli
Viridans strep
Pseudomonas
Group D strep
Enterococcus
Bacteroides fragilis
Bacteroides spp
Peptostreptococcus
Bilophila
Lactobacillus
Fusobacterium
Antimicrobial Prophylaxis
Common flora
Colon:
Bacteria make up to 90% of the dry weight of feces.
10
9
Organisms/ml feces
Must cover aerobic and anaerobic bacteria
Cefoxitin, Cefotetan
Levo + Flagyl
Zosyn ?, Ertapenem?
Aerobic Anaerobic
Escherichia coli
Enterococcus
Proteus
Streptococcus
Pseudomonas
Bacteroides fragilis
Peptostreptococcus
Bilophila
Lactobacillus
Fusobacterium
Surgeons Fault
Surgical Technique
Complications happen because you want
them to happen
Surgical Technique
Careful Tissue Handling
Ensure Adequate Blood Supply
Adequate Hemostasis
Debriedment of Necrotic Tissue
Removal of Foreign Bodies
Monofilament Sutures
Absorbable Sutures
Closed Suction Drains to prevent
seroma / hematoma
Avoid Open Drains (penrose)
Surgical Technique
Wound Closure
Delayed Primary Closure:
Heavily contaminated wounds or wounds with
devitalized tissue.
Allows for the body to develop adequate inflammatory /
cellular response to potential pathogens
Phagocytic cells progressively increase in number at the wound
edges to a peak at approximately day 5.
Capillary budding
Closure can be accomplished even with high bacterial counts.
Targeting closure of
wound at point of
optimal macrophage
numbers / activity
Patients Fault
Malnutrition
Pre-op TPN / Enteral Feeds
Early post-op Enteral Feeds
Tobacco
Pre / Intra / Post-op Warming
Glucose Control
Adequate resuscitation / CO / O2 deliver?
Specific Surgical Infections
Specific Surgical Infections
Non-Necrotizing Soft Tissue Infections
Cellulitis: Erythema, Warmth, Induration, Pain
Acute inflammatory response
Small vessel engorgement / stasis
Endothelial leakage / interstitial edema
PMN infilitrate
Should resolve with appropriate Abx coverage
Abscess: All of the above +
Sequelae of necrotic tissue, ischemia, pus
Fluctuance
Drainage / debriedment for local control
Specific Surgical Infections
Non-Necrotizing Soft Tissue Infections
Abscess:
Head and Neck: S. aureus +/- Strep
Axilla: Gram Negative component
Below Waist: Mixed aerobic and anaerobic gram neg.
Specific Surgical Infections
Necrotizing Soft Tissue Infections
Absence of clear local boundaries or palpable limit
Layer of necrotic tissue not walled off by
surrounding inflammation
Mortality 16% - 45%
Specific Surgical Infections
Necrotizing Soft Tissue Infections
Overlying skin may look remarkably NORMAL
Rapidly progressive infection within the superficial
subcutaneous fascial planes.
Bounded by deep investing fascia.
Inflammation / edema / +/- sub-Q air / Tense / Tender
to palpation
Late signs are erythema / ecchymosis / cyanosis /
blisters secondary to perforating vessel thrombosis.
Specific Surgical Infections
Necrotizing Soft Tissue Infections
Imaging:
CT, MRI: Inflammation (enhances on T2 imaging) /
edema within superficial tissues / Sub-Q gas ?
These modalities are sensitive but non-specific.
High index of suspicion to avoid delay in definitive
therapy Extensive fascial debriedment.
Specific Surgical Infections
Critical Care Medicine, 2004; 32(7): 1535 1541 Singapore
Retrospective Study
n = 89 pts admitted for Nec. Fasc.
n = 225 controls
Employed regression model to evaluate
various laboratory values at admission to
predict risk of Necrotizing Fasciitis.
Specific Surgical Infections
Specific Surgical Infections
Critical Care Medicine, 2004; 32(7): 1535 1541 Singapore
LRI NEC Predictive Value
Risk Group LRINEC SCORE PROBABILITY OF NEC.
FASC.
PREDICTIVE VALUE
Low Risk LRINEC < 5 50%
Moderate Risk LRINEC6 7 50% - 75% 6; PPV 92% NPV 96%
High Risk LRINEC 8 >75% 8; PPV 93.4%
Specific Surgical Infections
Specific Surgical Infections
Necrotizing Soft Tissue Infections
Finger Test
2 cm incision made down to deep fascia
+ Test
Lack of bleeding
Thrombosed vessels
Dishwater exudate
Lack of resistence to finger dissection
Frozen Section
Specific Surgical Infections
Necrotizing Soft Tissue Infections
Necrotizing Soft Tissue Infections require emergent
wide excision of all clinically involved tissues.
Re-operation within 24 hours, or sooner
Systemic support for impending severe sepsis
Extremity involvement often requires amputation to
control local infection.
Abx coverage for common organisms
Specific Surgical Infections
Necrotizing Soft Tissue Infections
Anaya DA et al. Predicting mortality in necrotizing soft tissue infections.
Surg Infect. 2009; 10(6): 517 522
Variable(on admission) # points
Heart rate > 110 1
Temp < 36
0
C 1
Creatinine > 1.5 mg/dl 1
Age > 50yr 3
WBC > 40 3
Hct > 50 3
Group Categories # Points Mortality Risk
1 0 2 6%
2 3 5 24%
3 6 88%
Specific Surgical Infections
Intra-abdominal and Retroperitoneal Infections
Mortality: 5 50%
Definitive therapy is NOT antibiotic management,
rather Operative or Interventional drainage.
a patient with fever and abdominal pain is not
given antibiotics without a plan leading to
surgery or other drainage procedure.
Administration of antibiotics in this setting before
diagnosis may obscure subsequent findings and
delay diagnosis and will certainly delay definitive
operative management.
Specific Surgical Infections
Intra-abdominal and Retroperitoneal Infections
Non-Surgical Causes of Acute Abdomen
Endocrine and Metabolic Causes
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Hereditary Mediterranean fever
Hematologic Causes
Sickle cell crisis
Acute leukemia
Other blood dyscrasias
Toxins and Drugs
Lead poisoning
Other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Other
Pancreatitis
Pyelonephritis
Salpingitis
Amebic Liver Abcess
Enteritis
SPB
Diverticulitis?
Cholangitis?
Does the Patient Need a Hole?
-Hx consistent with Surgical
Process?
-Peritonitis?
-Acidosis?
-Shock
-Non-op causes excluded
Emergent Operation
Source Control
Yes
Specific Surgical Infections
Intra-abdominal and Retroperitoneal Infections
Does the Patient Need a Hole?
-Hx consistent with Surgical
Process?
-Peritonitis?
-Acidosis?
-Shock
-Non-op causes excluded
Emergent Operation
Source Control
Yes
No
-Additional Labs
-Imaging
-Serial Exam
-Invasive Monitoring
-Percutaneous Drainage
-Other Intervention (ERCP, PTC,
Endoscopy)
Broad Spectrum
Antibiotics
Does the Patient Need a Hole?
Specific Surgical Infections
Intra-abdominal and Retroperitoneal Infections
Abx
Cefoxitin, Cefotetan
Timentin
Ertapenem
Unasyn
Imipenem
Meropenem
Zosyn
Flagyl
Clinda
Vanc
Non-Surgical Infections
UTI #1 nosocomial post-op infection
Pneumonia 3
rd
most common
Central Lines
Sinusitis