RIVOLTA Medival 26.11.pptx

La selezione del paziente: dalla preabilitazione all’intervento chirurgico Dott. UMBERTO RIVOLTA S.C. Chirurgia Generale Direttore Camillo Leonardo Bertoglio

Tips&Tricks per la gestione dei grandi difetti di parete

Esame strumentale:

• ecografia addome solo per ernie primitive senza diastasi in pz normopeso
• TAC addome completo smdc
• Classificazione (M/L - W – N- R – S – P)
• RDR
• CSI
• TANAKA – SABBAGH score
• Diastasi (post garvidanza o non)
• Co-morbidità (colelitasi, ernie inguinali, etc…)

Visita

• Co-morbidità
• Stratificazione del rischio. (CeDAR SCORE)
• Pregressa chirurgia
• PS (Performance Status) Limitazione QOL
• Per le donne in età fertile: desiderio di gravidanza

Flow-Chart difetti di parete

Arruolamento

IndIcazione a stratching fasciale intraoperatorio

Preabilitazione

• BTA
• PPP

In obese patients with BMI > 40 bariatric surgery should be considered

In obese patients with BMI > 40 and > 35, laparoscopic repair offers comparable complication and recurrence rates to non-obese patients in expert hands, and decreased compared to published literature for the open repair

• poor vascularisation of tissues
• impaired wound healing
• intra-abdominal pressure
• impaired bio-mechanics

Obesity is a risk factor for the occurrence of incisional hernias as well as for recurrence after repair

OBESITY AND VENTRAL HERNIA SURGERY

BMI > 35 e < 50 Kg/m2

BMI < 35 Kg/m2

Chirurgia Bariatrica

Pazienti con un BMI >50 hanno un rischio di recidiva di laparocele inaccettabile

Livello di evidenza: 2

Chirurgia bariatrica + Chirurgia di parete (ernie sintomatiche, piccoli difetti)

La sleeve gastrectomy è associabile a interventi di laparoalloplastica con protesi perchè non sussiste lo stesso rischio infettivo e nutrizionale del bypass

Livello di evidenza: 2

Chirurgia di parete (COMPLEX VENTRAL HERNIA, ASINTOMATICI, DIFETTI MAGGIORI)

Chirurgia di parete

Livello di evidenza: 2

Consulenza nutrizionale, regime dietetico, attività fisica

OBESITA’ PATOLOGICA E CVHR (Complex Ventral Hernia Repair)

• Riduzione dell’ossigenazione ematica e tissutale con alterato microcircolo (modificabile con la cessazione ): SSI

• Deposizione anomala di collagene (non modificabile con la cessazione): recidiva

• La cessazione del fumo andrebbe attuata ad almeno 30 giorni dalla chirurgia

• L’uso dei cerotti di nicotina non inficia i vantaggi perioperatori della cessazione del fumo

Livello di evidenza: 1

Livello di evidenza: 2

Fumo

• Il controllo glicemico è un elemento cruciale sia nel pre che nel postoperatorio. L’iperglicemia altera la chemiotassi, la fagocitosi, l’oxidative burst, aumentando il rischio di SSIs
• La chirurgia in elezione andrebbe postposta in caso di HgbA1c >8%: il target è un valore prossimo a 6,5%
• Il diabetico scompensato viene indirizzato al diabetologo
• Il controllo glicemico è essenziale in particolare nelle prime 24h per massimizzare l’attività dei neutrofili
• L’intervallo glicemico nel postoperatorio deve essere compreso tra 120 – 160mg/dl
• Non scendere al di sotto dei 110mg/dl

Diabete

• L’integrazione preoperatoria con nutrienti modula positivamente la risposta allo stress chirurgico
• ω3: riduzione delle citochine proinfiammatorie, riduzione dei Th1 e Th2 (T helper)
• Arginina: guarigione delle ferite, aumento del microcircolo attraverso l’NO
• Assumere 3h prima dell’intervento una soluzione isotonica di carboidrati “carbohydrate loading”riduce la risposta allo stress e la resistenza insulinica

Integratori nutrizionali

• Chirurghi
• Anestesisti
• Fisioterapisti
• Nutrizionisti
• Diabetologi
• Terapisti del dolore
• Infermieri
• Radiologi
• Nella pratica corrente i pazienti con lunga aspettativa di vita e fattori di rischio modificabili rappresentano il 50 – 80% dei casi

TEAM ERAS

Recommendation: Umbilical Hernia Repair with mesh should be considered as a concurrent procedure when performing laparoscopic groin hernia repair (Grade: Weak).

Concurrent umbilical repair during other procedures The surgeon needs to take the size and complexity of the hernia, the risk of infection, the patient comorbidity and the patient’s wishes into account when deciding on combining surgical procedures.

Inguinal Hernia: Concurrent laparoscopic hernia repair can be performed together with an open hernia repair of the umbilical defect. The principles for both repairs remain the same. Either totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) can be safely performed followed by umbilical repair. Due to the high risk of recurrence the repair should be performed with mesh.

Laparoscopic Cholecystectomy: Umbilical hernias occur in approximately 8% of patients undergoing laparoscopic cholecystectomy.73 Combined procedures are safe in “centres with adequate experience in management of laparoscopic ventral hernia repairs and by experienced laparoscopic surgeons.” Mesh repair has the lowest recurrence rate. There is conflicting evidence about wound complication rates, but concurrent mesh repair appears to be safe and to carry no significant risks of wound complications.

Concurrent umbilical repair during other procedures

Recommendation: Concurrent umbilical hernia repair should be performed during laparoscopic cholecystectomy (Grade: Moderate).

Perioperative control of the ascites is critical to a successful outcome. The timing of the hernia repair in liver transplant candidates should be made in conjunction with the transplant team. Trial randomised patients with Child-Pugh A and B cirrhosis to either tissue or mesh repair. On six month follow up, 14% of the tissue repair patients had recurrence compared to 3% in the mesh group.

Recommendation: In patients with liver disease, an early elective mesh repair of umbilical hernia is encouraged. Preoperative control of ascites is especially critical to a successful outcome (Grade: Moderate).

Umbilical hernia repair with ascites Umbilical hernias occur in 20% of patients with liver cirrhosis complicated by ascites.Historically, mortality rates and hernia recurrence in patients with cirrhosis were prohibitively high and the accepted strategy was to reserve surgery for patients with a complication (incarceration, skin erosion and rupture). Medical care of cirrhotic patients has improved and it has been shown that elective hernia repair is associated with fewer complications and may reduce overall mortality. Contraindications to elective surgery include

• acute liver failure
• acute viral hepatitis
• acute alcoholic hepatitis
• refractory ascites

Fertility and Pregnancy Most surgeons are reluctant to place an Intra-peritoneal Onlay Mesh (IPOM) in fertile women wishing to conceive. There is concern about adhesion formation after intraperitoneal mesh placement, though there is a paucity of data on the topic. There is limited data and no conclusions can be drawn. If the baby is to be delivered by Caesarean section, it is often feasible to perform a concurrent repair taking advantage of the concomitant tissue expansion at the time of the caesarean. There is limited data that mesh placement is safe and that LOS and complication rates are not increased. If born by normal vertex delivery (NVD) the safest is to offer delayed repair. Recommendation: Perform a retro-rectus mesh hernia repair. Avoid intraperitoneal mesh placement in women wishing to conceive (Grade: Weak). Mesh repair can be performed at the time of Caesarean Section (Grade: Moderate).

• Future abdominal surgery

Planned future surgery does not preclude mesh-placement. Every precaution should be taken to avoid adhesion formation. Should laparotomy be indicated after mesh repair, care should be taken on entry into the peritoneal space. It is important to re-suture the mesh on closure with non-absorbable suture material and to consider further mesh reinforcement if the fascia or mesh is incomplete.

La selezione della Patologia

N – NUMBER OF DEFECTS S – ASSOCIATED SYMPTOMS S0 S1 S2 R – RECURRENCE (R1, R2…) P – PRESENCE OF PROSTHESES P1 P2 P3

Over 0.21, the likelihood of an interpositional repair in addition to component separation becomes much greater.

CSI – COMPONENT SEPARATION INDEX

If the RDR is > 2, routine surgical repair will be able to close the abdominal wall defect in 90% of cases.

(49mm + 43mm )/ 157mm = 0.58

(73mm + 81mm )/ 51mm = 3

If the RDR is < 1.5, in more than 52% of the repairs, additional component separation technique is required.

RDR – RECTUS DEFECT RATIO

ADDITIONAL STRATEGY (BTA/PPP/Stretching…)

• HSV= cc x tra x ap x 0.52
• ACV= cc x tra x ap x 0.52

TANAKA SCORE HSV/ACV 25% SABBAGH SCORE HSV/TPV 20%

LOSS OF DOMAIN

Considera BTA se 5-10 cm

* Laparoscopic Intracorporeal Rectus Aponeuroplasty

STOP Fumo 30gg ↓ Peso / obesità Diabete Gravidanza / deisderio di… Patologie concomitanti

Preabilitazione Paziente

Preab. Parete

> 10 cm o RDR < 2

Rives TAR Monolat Fasciotens

PPP

TC Addome senza mdc

LoD > 20% Tanaka Score

PCS + TAR

6 settimane

4/6 settimane

BTA

TC Addome senza mdc

eTEP (Diastasi) IPOM Plus

VLS

Open

Si

No

IPOM ± Plus LIRA*

Recidivo?

Plastica VLS

VLS

Plastica anteriore

< 10 cm

Laparocele

ERNIE INCISIONALI

“IL LAVORO DI SQUADRA FA AVVERARE I SOGNI”