Recovery after abdominal wall reconstruction.

Incisional hernia is a common long-term complication to abdominal surgery, occurring in more than 20% of all patients. Some of these hernias become giant and affect patients in several ways. This patient group often experiences pain, decreased perceived body image, and loss of physical function, which results in a need for surgical repair of the giant hernia, known as abdominal wall reconstruction. In the current thesis, patients with a giant hernia were examined to achieve a better understanding of their physical and psychological function before and after abdominal wall reconstruction. Study I was a systematic review of the existing standardized methods for assessing quality of life after incisional hernia repair. After a systematic search in the electronic databases Embase and PubMed, a total of 26 studies using standardized measures for assessment of quality of life after incisional hernia repair were found. The most commonly used questionnaire was the generic Short-Form 36, which assesses overall health-related quality of life, addressing both physical and mental health. The second-most common questionnaire was the Carolinas Comfort Scale, which is a disease specific questionnaire addressing pain, movement limitation and mesh sensation in relation to a current or previous hernia. In total, eight different questionnaires were used at varying time points in the 26 studies. In conclusion, standardization of timing and method of quality of life assessment after incisional hernia repair was lacking. Study II was a case-control study of the effects of an enhanced recovery after surgery pathway for patients undergoing abdominal wall reconstruction for a giant hernia. Sixteen consecutive patients were included prospectively after the implementation of a new enhanced recovery after surgery pathway at the Digestive Disease Center, Bispebjerg Hospital, and compared to a control group of 16 patients included retrospectively in the period immediately prior to the implementation of the pathway. The enhanced recovery after surgery pathway included preoperative high-dose steroid, daily assessment of revised discharge criteria and an aggressive approach to restore bowel function (chewing gum and enema on postoperative day two). Patients who followed the enhanced recovery after surgery pathway reported low scores of pain, nausea and fatigue, and were discharged significantly faster than patients in the control group. A non-significant increase in postoperative readmissions and reoperations was observed after the introduction of the enhanced recovery after surgery pathway. Study III and IV were prospective studies of patients undergoing abdominal wall reconstruction for giant incisional hernia, who were compared to a control group of patients with an intact abdominal wall undergoing colorectal resection for benign or low-grade malignant disease. Patients were examined within a week preoperatively and again one year postoperatively. In study III, the respiratory function and respiratory quality of life were assessed, and the results showed that patients with a giant incisional hernia had a decreased expiratory lung function (peak expiratory flow and maximal expiratory pressure) compared to the predicted values and also compared to patients in the control group. Both parameters increased significantly after abdominal wall reconstruction, while no other significant changes were found in objective or subjective measures at one-year follow-up in both groups of patients. Lastly, study IV examined the abdominal wall- and extremity function, as well as overall and disease specific quality of life. We found that patients with a giant hernia had a significantly decreased relative function of the abdominal wall compared to patients with an intact abdominal wall, and that this deficit was offset at one-year follow-up. Patients in the control group showed a postoperative decrease in abdominal wall function, while no changes were found in extremity function in either group. Patients reported improved quality of life after abdominal wall reconstruction. In summary, the studies in this thesis concluded that; standardization of patient-reported outcomes after incisional hernia repair is lacking; enhanced recovery after surgery is feasible: after abdominal wall reconstruction and seems to lower the time to discharge; patients with giant incisional hernia have compromised expiratory lung function and abdominal wall function, both of which are restored one year after abdominal wall reconstruction.

Diagnóstico y tratamiento de la hernia de Spieghel / Diagnostic and treatment of the Spigelian hernia

El objetivo de este trabajo es presentar la experincia adquirida como residentes de cirugía general en el diagnóstico y tratamiento de la Hernia de Spieghel. Entre mayo de 1994 y mayo de 1997 fueron atendidos en nuestro hospital 4 pacientes portadores de Hernia de Spieghel. Tres pacientes eran masculino y uno femenino, con una edad media de 58,7 años. El tumor pararrectal y el dolor abdominal fueron los síntomas más comunes. Un paciente presentó abdomen agudo obstructivo. Los métodos complementarios de diagnóstico utilizados fueron la ecografía y el colon con enema. Todos los pacientes fueron operados con diagnóstico de Hernia de Spieghel. La técnica utilizada consistió en reparación anatómica del defecto herniano con sutura contínua monoplano. Tres pacientes fueron abordados por una incisión transversa pararrectal y uno por vía abdominal. No hubo morvilidad ni mortalidad. Pese al corto período de seguimiento no hay recidivas. La Hernia de Spieghel no es una patología frecuente, debemos pensar en ella ante la presencia de un paciente que presente tumor y dolor abdominal acompañado a una dibilidad en la pared anterior del abdomen. Debido a la posibilidad de estrangulación, el tratamiento debe ser quirúrgico. (AU)

[Bipolar impulses or direct current as an adjuvant treatment of incisional hernia? Comparative experimental animal study]. / Bipolare Impulse oder Gleichstrom als adjuvante Behandlung von Narbenhernien? Tierexperimentelle Vergleichsuntersuchungen.

The electrostimulation of the cicatricial healing in the abdominal wall were tested in 119 Wistar rats by means of bipolar rectangularly pulsed current (0.87 Hz, +/- 25 mu A) and direct current (1 mu A). Doubling of the fascia of an abdominal wall hernia was carried out in three groups of rats. In the first group the operational region was stimulated by rectangularly pulsed current, strong proliferated cicatrices were formed with premature production of fibroblasts and collagenous fibres, fast maturation, and high strength. In the second group it was stimulated by direct current, a less exact longitudinal orientation of the collagenous fibres and a slower cicatricial maturation were shown. The third group applied as a control showed a cicatricial distension up to 5 mm. The electrostimulation of the proliferation of connective tissue and cicatricial healing could be pointed out between different tissues (peritoneum and fascia).