Giant hernia - Forum

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Jorjo

Giant hernia - Ärzteforum

Post#1 »

Just to ask you if you'd operate a 78 yo male, carrying a coronary cardiopathy, diabetes type 2, a xiphoescoliosis and a bilateral hernia,one, the left rather small, recidivated, the other,the right side one, giant ,huge inguinoescrotal hernia that has inside its sac almost all abdominal viscerae and descends down to his knees,measuring about 30 or 40 cms long and 15 cms wide...difficult to reduce but possible to and that makes his miserable life intolerant.


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Surgeon

Re: Giant hernia - Ärzteforum

Post#2 »

Of course. I would plan to do these together under epidural anaesthesia. Either mesh/plug or Lichtenstein technique. If the anaethesthetist wasn't happy, I'd do these sequentially under local, since you have stated that these are reducible.

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A Doctor

Re: Giant hernia - Ärzteforum

Post#3 »

I would fix this patient. I would proceed without delay if he was not in heart failure, not having unstable angina, has not had a recent MI, and if his hypertension were under control. I would also place the patient on a beta blocker (assuming no COPD) and aspirin, if not already on aspirin. I probably would stop the ASA about 5 days pre-op and restart post-op. Of course, I would also tell the patient that he may die from the operation. I would probably elect for general anesthesia. In this situation, a well done GA is probably the most reliable. A poorly done local, spinal, or epidural is probably more stressful.

Jorjo

Re: Giant hernia - Ärzteforum

Post#4 »

Your statements are perfectly appliable but I would like you to understand that the hernia is a real giant one, measures around 15 x 8 cms and it contains inside almost all the muscled viscerae of the abdo..at least a big part of all the small bowel and probably some part of the large bowel has slided into the sac.

Given the best conditions for the pt. to be operated under regional o general anesthesia, what would you advice to be done as a surgical procedure?

Laparoscopic approach, mesh plasty or what else in order to move back all the contents and repair the huge parietal deffect?

Would you consider an orquiectomy (the testicle is practically atrophied) ?

Anything else?

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Resident

Re: Giant hernia - Ärzteforum

Post#5 »

I recall the half-life of ASA as 10 days. I will have to recheck this, but I am fairly confident. ASA provides an irreversable effect on cyclooxygenase, as apposed to the NSAIDs which are reversable.

Hans

Re: Giant hernia - Ärzteforum

Post#6 »

A GA or at least a spinal would help getting the abdo relaxed enough to get all the giblets back in to the tummy. In old gents with huge hernias I usually discuss the benefits of orchidectomy as to my mind it simplifies proceedings. This case sounds like a good challenge - and what sort of surgeons would we be if we did not enjoy a good challenge - I would certainly offer him surgery. In the immortal words of (probably) some famous American "go for it!"

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Lady Surgeon

Re: Giant hernia - Ärzteforum

Post#7 »

I don't know about this. I would be quite concerned about excessive intra-abdominal pressure, excessive pressure on his diaphragm restricting ventilation, etc. Just because we can do it doesn't mean it is the best thing for the patient.

In the olden days, some surgeons injected 1000+ cc of air frequently until they enlarged the abdominal cavity enough to accomodate the intestines which have lost their abdominal domain.

Arizona

Re: Giant hernia - Ärzteforum

Post#8 »

You clearly stated that this hernia is REDUCIBLE. There is no good reason to expose the pt to general anaesthesia, unless the surgeon is unfamiliar with repair under LA, and nobody locally has confidence to do it under local, or no anaesthetist is happy with epidural locally. There should be little concern about "loss of domain" unless there exists a worry about the patient's cardiorespiratory status with the hernia reduced, and we've been told it's reducible.

Grandpa Phil

Re: Giant hernia - Ärzteforum

Post#9 »

Laparoscopic approach, mesh plasty or what else in order to move back all the contents and repair the huge parietal deffect?...

I WOULD MOST LIKELY DO AN OPEN REPAIR WITH MESH

Would you consider an orquiectomy (the testicle is practically atrophied) ?...

SURE, I WOULD TRY TO KEEP THIS CASE AS SIMPLE AS POSSIBLE. IF REMOVAL OF THE TESTICLE ACCOMPLISHES THIS GOAL, I WOULD REMOVE IT. I HAVE NOT FOUND ORCHIECTOMY HELPFUL, THOUGH.

Anything else?...

IN TERMS OF HIS CARDIAC RISK, IF HE DOES HAVE HIGH GRADE OBSTRUCTIVE CORONARY LESIONS, THEN I BELIEVE THE "LEAST STRESSFUL, MOST STRAIGHTFORWARD APPROACH" IS THE IDEAL. I DO NOT HAVE MUCH EXPERIENCE WITH THE LAPAROSCOPIC TECHNIQUE. I HAVE DONE MANY REPAIRS USING LOCAL ANESTHESIA. IN MY HANDS, I THINK REPAIRING A HERNIA THAT YOU DESCRIBE WITH LOCAL WOULD BE MORE STRESSFUL TO THE PATIENT THAN A WELL PERFORMED GENERAL ANESTHETIC. HERE, THE GOAL IS TO MINIMIZE HEMODYNAMIC STRESS TO MYOCARDIUM AT RISK FOR ISCHEMIA (OXYGEN DEMAND PROPORTIONAL TO BP AND HR). OF COURSE, A POORLY DONE GENERAL ANESTHETIC (OR SPINAL OR LOCAL) WOULD MOST LIKELY SUBJECT THE PATIENT TO THE HIGHEST RISK. THE OTHER RISK IS PLAQUE RUPTURE/THROMBOSIS....IE, PUT YOUR PATIENT ON ASPIRIN.

I HOPE YOUR PATIENT DOES WELL. THANKS FOR POSTING YOUR CASE. IT IS AN IMPORTANT PROBLEM FOR SURGEONS.

Hans

Re: Giant hernia - Ärzteforum

Post#10 »

Just a small point, I think we have touched on this before - regarding spinal anaesthetic, its quick, pretty safe and requires almost no anaesthetic experience, and its duration of action ideally suits it to a fairly short procedure like hernia repair. The main advantage of an epidural as I see it is the ability to top it up for post op analgesia or for a more prolonged operation. In my hospital we have no resident specialist anaesthetists and we therefore use spinal anaesthesia a lot for Caesars, hernias, prostatectomies and many other procedures "below the belt". I know you like local, but do you have anything against spinal?

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