Perianal Complaints

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Diarrhea: Diagnosis and Management

Diarrhea is defined as liquid stool, rather than soft or formed stool, which has a daily weight exceeding 250 g and is accompanied by excess fluid loss and a number of bowel movements. Four general mechanics are responsible for diarrhea: morphologic alterations of intestinal mucosa, osmotic malabsorption, secretory derangement, and aberrant intestinal motility.

The management of diarrhea begins with a history and physical examination, including a thorough drug, dietary, and travel history as well as questions regarding food ingestion, recent medication changes, exposure to others with diarrhea, and family history. Chronic diarrhea lasts at least 3 to 6 weeks.

All patients with diarrhea should have stool samples tested for fecal leukocytes, occult blood, excess fat, and bacterial cultures. The presence of white blood cells (WBCs) implies an exudative or inflammatory process, usually as a result of an infectious enteritis or inflammatory bowel disease. The presence of blood in the stool without WBCs should arouse suspicion for neoplasm or colonic ischemia. Evaluations for ova and parasites, fecal qualitative fat, or mucosal biopsy are indicated in select cases.

Inflammatory diarrhea is characterized by the presence of fecal leukocytes and persistent diarrhea despite fasting. Infections are the most common cause. Etiologies include viral gastroenteritis (rotavirus), AIDS-related enteritis (giardia, salmonella, cryptosporidium), and pseudomembranous colitis (Clostridium difficile). Assays for C. difficile toxin and visual identification of organisms (giardia) on stain or culture can be diagnostic; antibiotic therapy should be directed against the causative agent. If negative, endoscopy should be performed to directly visualize the mucosa.

Examination of the stool for qualitative fecal fat can help diagnose malabsorption. A 24-hour fecal fat measurement should be ordered; greater than 10 g of fat per 24-hour period is indicative of malabsorptive or maldisgestive steatorrhea.

Exogenous agents that may produce an osmotic diarrhea include laxatives (magnesium sulfate); magnesium-based antacids; dietetic foods with sorbitol, mannitol, or xylitol; and certain drugs used chronically (cholestyramine, colchicines, neomycin, and lactulose).

Endogenous sources are caused by congenital conditions including disaccharidase deficiencies or generalized malabsorptive/maldigestive processes (cystic fibrosis, congenital lymphangiectasia).

Acquired causes include pancreatic exocrine deficiency, bacterial overgrowth, celiac sprue, bile salt diarrhea, thyrotoxicosis, and adrenal insufficiency. Bacterial overgrowth syndromes can be confirmed by a hydrogen breath test that detects fermentation of carbohydrates by direct measure of hydrogen in the breath. Patients with small-bowel bacterial overgrowth have hydrogen peaks within 3 hours; those with colonic fermentation peak later, thereby identifying the site of the problem.

Secretory diarrhea is characterized by watery stools with volumes greater than 1 L per day. Etiologies include enterotoxin-induced secre-

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best measures to use to avoid the disastrous complications associated with undrained perineal sepsis. When drained either surgically or spontaneously, 50% of abscesses have persistent communication with the crypt, creating a fistula from the anus to the perianal skin or fistula in ano. A fistula in ano is not a surgical emergency because the septic focus has drained.

As in Case 1, an abscess typically causes severe, continuous, throbbing anal pain that may worsen with ambulation and straining. Occasionally, patients present with fever, urinary retention, and lifethreatening sepsis, which especially is true in diabetics and the immunocompromised host.

Physical examination of the patient with an abscess reveals a tender perianal or perirectal mass. No imaging studies are necessary in uncomplicated abscess fistulous disease, but imaging studies such as sinograms, transrectal ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) may be useful in the evaluation of complex or recurrent disease. An approach to surgical management of perianal abscesses/fistulas is shown in Algorithm 26.2.

Abscess fistula disease of cryptoglandular origin must be differentiated from complications of Crohn’s disease, pilonidal disease, hidradenitis suppurativa, tuberculosis, actinomycosis, trauma, fissures, carcinoma, radiation, chlamydia, local dermal processes, retrorectal tumors, diverticulitis, and ureteral injuries. Five percent to 10% of patients with Crohn’s disease initially present with anorectal abscess or fistulous disease. A colonic source may be suspected in a patient with known inflammatory bowel disease or diverticular disease.

The complications of an undrained anorectal abscess may be severe. If the abscess is not drained surgically or spontaneously, the infection may spread rapidly, which may result in extensive tissue loss, sphincter injury, and even death. Abscesses should be drained surgically. Patients often require drainage in the operating room, where anesthesia allows for adequate evaluation of the extent of the disease.

Algorithm 26.2. Algorithm for an approach to the surgical management of perianal abscesses/fistulas.

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Figure 26.2. Goodsall’s rule: External openings anterior to a line drawn between the 3 and 9 o’clock positions communicate with an internal opening along a straight line drawn toward the dentate line. Posterior external openings communicate with the posterior midline in a nonlinear fashion. The exception may be an interior opening that is greater than 3 cm from the dentate line. (Reprinted from Marti M-C, Givel J-C, eds. Surgical Management of Anorectal and Colonic Diseases, 2nd ed. Heidelberg: Springer-Verlag, 1999, with permission.)

Patients with a chronic or recurring abscess after apparent adequate surgical drainage often have an undrained, deep, postanal space abscess that communicates with the ischiorectal fossa via a “horseshoe fistula.” Immunocompromised patients are a particular challenge, as seen in Case 1. These patients are more prone to necrotizing anorectal infections.

The treatment of fistulas is dictated by the course of the fistula. Goodsall’s rule is of particular assistance in identifying the direction of the tract (Fig. 26.2) in fistulas with posterior external openings, but reliability is decreased anteriorly and in particular as the distance from the verge is increased.

Anal Fissure/Ulcer

An anal fissure is a split in the anoderm. An ulcer is a chronic fissure. Fissures most frequently occur in the midline just distal to the dentate line. Fissures result from forceful dilation of the anal canal, most commonly during defecation. Classically, the initial insult is believed to be a firm bowel movement. The pain associated with the initial bowel movement is great, and the patient therefore ignores the urge to defecate for fear of experiencing the pain again. A self-perpetuating cycle of pain, poor relaxation, and reinjury results.

Fissures cause pain and bleeding with defecation. The pain is often tearing or burning, worse during defecation, and subsides over a few hours. Anoscopy and proctosigmoidoscopy should be deferred until healing occurs or the procedure can be performed under anesthesia.

Although anoscopy and rigid sigmoidoscopy may not be performed

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in the initial evaluation of a patient with a fissure, they must be performed during a subsequent visit because the presence of associated anorectal malignancy or inflammatory bowel disease must be excluded.

Ulcers occurring off the midline or away from the mucocutaneous junction are suspect. Crohn’s disease, anal TB, anal malignancy, abscess/fistula disease, cytomegalovirus (CMV), herpes, chlamydia, syphilis, AIDS, and some blood dyscrasias all may mimic certain aspects of fissures/ulcer disease.

Treatment using stool softeners, bulk agents, and sitz baths is successful in healing 90% of anal fissures. Patients are instructed to soak in a hot bath and contract the sphincters to identify the muscle in spasm and then focus on relaxing that muscle. Botox infiltration into the internal sphincters may be effective in the treatment of anal fissures. Lateral internal sphincterotomy is the procedure of choice for many surgeons after conservative measures have failed.

Hemorrhoids

Patients with perianal pathology often present or are referred with a chief complaint of “hemorrhoids.” A thorough history frequently suggests the diagnosis. Those individuals with painless bleeding due to hemorrhoids must be distinguished from those with bleeding from colorectal malignancy, inflammatory bowel disease, diverticular disease, and adenomatous polyps. Rectal prolapse must be distinguished from hemorrhoids because it is safe to band a hemorrhoid but not a prolapsed rectum.

Hemorrhoidal tissues are part of the normal anatomy of the distal rectum and anal canal. The disease state of “hemorrhoids” exists when the internal complex becomes chronically engorged or the tissue prolapses into the anal canal as the result of laxity of the surrounding connective tissue and dilatation of the veins. External hemorrhoids may thrombose, leading to acute onset of severe perianal pain. An approach to the management of hemorrhoid disease is shown in Algorithm 26.3.

Internal hemorrhoids may have two main pathophysiologic mechanisms seen in two distinct but not exclusive groups: older women and younger men. Internal hemorrhoids originate above the dentate line and are lined with insensate rectal columnar and transitional mucosa. In older women, the pathophysiologic mechanism may be related to earlier pregnancy or chronic straining, which leads to vascular engorgement and dilatation, resulting in stretching and disruption of the supporting connective tissue surrounding the vascular channels. Another suggested pathologic mechanism, and the one that may be more important in younger men, is that of increased resting pressures within the anal canal, leading to decreased venous return. Internal hemorrhoids typically do not cause pain but rather bright-red bleeding per rectum, mucous discharge, and a sense of rectal fullness or discomfort.

External hemorrhoids may develop an acute intravascular thrombus, which is associated with acute onset of extreme perianal pain. The pain

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Special circumstances

•Pregnancy

•Inflammatory bowel disease

Algorithm 26.3. Algorithm for an approach to the management of hemorrhoid disease.

usually peaks within 48 hours. Repeated episodes of dilatation and thrombosis may lead to enlargement of the overlying skin, which is seen as a skin tag on physical exam. As in Case 2, the acutely thrombosed external hemorrhoid is seen as a purplish, edematous, tense subcutaneous perianal mass that is quite tender.

The complications of internal or external hemorrhoids are the indications for medical or surgical intervention: bleeding, pain, necrosis, mucous discharge, moisture, and, rarely, perianal sepsis. Initial medical management for all but the most advanced cases is recommended. Dietary alterations, including elimination of constipating foods (e.g., cheeses), addition of bulking agents, stool softeners, and increased intake of liquids are advised. Internal hemorrhoids that fail to respond to medical management may be treated with elastic band ligation, sclerosis, photocoagulation, cryosurgery, excisional hemorrhoidectomy, and many other local techniques that induce scarring and fixation of the hemorrhoids to the underlying tissues. The acutely thrombosed external hemorrhoid may be treated with excision of the hemorrhoid or clot evacuation if the patient presents within 48 hours of onset of symptoms. If the patient presents more than 48 hours after onset of symptoms, conservation management with warm sitz baths, high-fiber diet, stool softeners, and reassurance is advised.

Pilonidal Disease

Patients with pilonidal disease may present with small midline pits or an abscess(es) off the midline near the coccyx or sacrum. The workup is limited to a physical exam unless one suspects Crohn’s disease; then

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edges, and have been present for more than 2 years before detection.

All chronic or nonhealing ulcers of the perineum should be biopsied to rule out squamous cell carcinoma.

Tumors of the Anal Canal

Epidermoid Carcinoma

Generally, there is a long history of minor perianal complaints such as bleeding, itching, or perianal discomfort. Early lesions that are small, mobile, confined to the submucosa, and well differentiated may be treated with local excision. Radiation therapy or chemoradiotherapy is the preferred treatment option for larger lesions of the anal canal.

Summary

Patients with perianal problems often are referred with a diagnosis of hemorrhoids. The sometimes life-threatening causes of perianal complaints require attention to history and a thorough physical examination. While hemorrhoidal disease often can be treated expectantly or by local therapies, improperly treated infectious and malignant causes of such complaints often result in devastating consequences.

Selected Readings

Allal A, Kurtz JM, Pipard G, et al. Chemoradiotherapy versus radiotherapy alone for anal cancer: a retrospective comparison. Int J Radiat Oncol Biol Phys 1993;27(1):59–66.

Beahrs OH, Wilson SM. Carcinoma of the anus. Ann Surg 1976;184(4):422– 428.

Bernstein WC. What are hemorrhoids and what is their relationship to the portal venous system? Dis Colon Rectum 1983;25(12):825–834.

Cirocco WC. Lateral internal sphincterotomy remains the treatment of choice for anal fissures that fail conservative therapy [letter; comment]. Gastrointest Endosc 1998;47(2):212–214.

Duthie HL, Gairns FW. Sensory nerve-endings and sensation in the anal region of man. Br J Surg 1960;47:585–594.

Haas PA, Fox TA Jr, Haas GP. The pathogenesis of hemorrhoids. Dis Colon Rectum 1984;27(7):442–450.

Hiltunen KM, Matakainen M. Anal manometric findings in symptomatic hemorrhoids. Dis Colon Rectum 1985;28(11):807–809.

Lin JK. Anal manometric studies in hemorrhoids and anal fissures. Dis Colon Rectum 1989;32(10):839–842.

Milligan ETC, Morgan CN. Surgical anatomy of the anal canal. Lancet 1933;2: 1150–1156.

Möller C, Saksela E. Cancer of the anus and anal canal. Acta Chir Scand 1970;136(4):340–348.

Papillon J, Montbarron JF. Epidermoid carcinoma of the anal canal. Dis Colon Rectum 1987;30(5):324–333.

Thomson WH. The nature of haemorrhoids. Br J Surg 1975;62(7):542–552.

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Vasilevsky C-A. Results of treatment of fistula-in-ano. Dis Colon Rectum 1984;28:225–231.

Welton ML, Varma MG, Amerhauser A. Colon, rectum, and anus. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001.

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gurgles heard in the abdomen, and a slightly pink, skin-covered, very tender lump was present in the right groin. Abdominal x-ray: dilated intestinal loops with air-fluid levels. Laboratory studies: hemoglobin, 14.6; BUN, 24; electrolytes normal; urine specific gravity, 1.028.

Case 2

A male college student, age 20, presents with a 4-year history of intermittent soft mass in his groin and a large lump in the right side of the scrotum, which is now uncomfortable. He does not notice any groin mass on awakening, but he becomes aware of the groin and scrotal masses later in the morning, toward noon.

Definitions

A hernia is present when an object goes through an opening and is now in any unexpected location. There may be a covering of the object; this covering, called the sac, usually is the peritoneum. An organ, a portion of omentum, or part of the intestine, bladder, or stomach may herniate through an opening in the abdominal wall or diaphragm. This has occurred in both Case 1 and Case 2.

A femoral hernia, much more common in women, presents through the femoral canal, and an indirect inguinal hernia protrudes through the abdominal wall in the spermatic cord or alongside the round ligament. Pediatric inguinal hernias are indirect. Direct inguinal hernias are rare in females and in males younger than 35 years of age.

An internal hernia occurs when the intestine goes through an opening inside the abdominal cavity. In a Richter’s hernia (Case 1), only a part of the intestinal wall, covered by a sac formed by the overlying peritoneum, protrudes through an opening (usually in the femoral canal), and the intestinal lumen remains open. In Case 1, the woman has both a lump in the groin and not complete intestinal obstruction, meaning that she could have a knuckle of bowel wall caught in an opening but with an open lumen, as in a Richter’s hernia. This patient is dehydrated and seriously ill! (See Algorithms 27.1 and 27.2.)

If an organ or a portion of the intestine uncovered by peritoneum protrudes through and forms part of the hernia sac, this is called a sliding hernia. When an intestinal loop comes out through an opening and this hernia does not go back by itself or cannot be gently pushed back, the hernia cannot be reduced. The hernia is incarcerated. When part of the intestine (or stomach) is incarcerated, there can be a shutting off of the venous drainage and/or the arterial circulation; this is now a strangulated hernia. Gangrenous changes develop, leading to possible perforation and possible death.

Groin Masses: Differential Diagnosis

These are the differential diagnoses for groin masses.

•Inguinal hernia: Protrudes through the internal ring, at the level of the public tubercle; exits via the external ring (see Algorithm 27.1).

Peritoneum

Post. rectus sheath

Transversus abd. m.

Transversalis fascia

A

Anterior rectus sheath

Rectus abdominis m.

B

Figure 27.1. Abdominal wall layers: (A) above the semilunar line of Douglas;

(B) below the semilunar line. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)

The inguinal canal courses obliquely from the internal ring opening in the transversalis fascia to the pubic bone and the external ring opening in the external oblique. The spermatic cord in the male comes through the internal ring; the external ring is where the spermatic cord exits to head down into the scrotum. Included in this “cord” are superficial and external spermatic fascial layers, cremaster muscle, external spermatic artery (in the cremaster), internal spermatic fascia, vas deferens, testicular artery, pampiniform plexus of little veins, and some sympathetic fibers. The genital branch of the genital femoral nerve, often said to be in the spermatic cord, actually courses through the internal ring in the edge of posterior cremaster fibers and easily is separated from the cord. This nerve lies posterior to the cord with its accompanying vessels in the inguinal canal. The boundaries of the inguinal canal are the transversalis fascia posterior, external oblique

27. Groin Hernias and Masses, and Abdominal Hernias 485

Femoral canal

Figure 27.3. Indirect hernias occur through the internal ring. Direct inguinal hernias occur through Hesselbach’s triangle, which lies between the inguinal ligament, the rectus sheath, and the inferior epigastric vessels. Femoral hernias occur through the femoral canal, which lies between the inguinal ligament, the lacunar ligament, Cooper’s ligament, and the femoral vein. Fruchaud’s myopectineal orifice refers to the entire musculoaponeurotic area through which inguinal and femoral hernias can occur. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)

borders: the superior inguinal ligament, the inferior Cooper’s ligament, and the medial half-moon–shaped lacunar ligament. Because of this, these hernias frequently are incarcerated and are prone to develop strangulation, with intestinal wall gangrene, as in Case 1.

Diagnosis

Diagnosis can be difficult because of the short distance between the inguinal canal and the medial groin presentation site of the femoral hernia. The usual history includes the awareness of a lump in the groin, but it is in the leg crease where the pelvis meets the thigh medially. Direct pain or tenderness, vague groin or lower abdominal discomfort, nausea, and discomfort on prolonged standing or while walking are frequent findings. Examination is most helpful with the patient standing. If, when she strains and increases intraabdominal pressure, a lump is seen or felt, the base of the femoral hernia will be below the level of the top of the pubic bone, as noted in Algorithm 27.1. Also, if the examiner’s forefinger is in the femoral canal when the patient strains, the fingertip can be backed away slowly, allowing the

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hernia to pop out of the canal. With an incarcerated hernia in a woman, there is some tissue swelling, and it can be difficult to differentiate between femoral or inguinal hernia. The gentlest pressure can be tried with the patient supine to see whether an inguinal hernia will reduce.

Caution is required because an incarcerated femoral hernia usually should be diagnosed in the operating room; no significant pressure should be applied to attempt reduction (see Algorithm 27.2)!

Surgical Treatment of Femoral Hernia

The surgeon must know several operative methods and be able to choose the best method for the particular patient and situation. In the open, preperitoneal approach, the surgeon opens the inguinal canal and then may enter the preperitoneal space through Hesselbach’s triangle or by going above the canal and entering through the posterior rectus sheath. A piece of nonabsorbable mesh may be used for repair.

In approaching the femoral hernia from below, one incises over the femoral canal, dissects through the fat and lymphatic tissue, reduces a sac found, and occludes the canal with rolled mesh or with stitched tissue adjacent. The sac is opened to check for evidence of ischemic intestine (bloody fluid). Normal postoperative course includes the following. The individual has moderate pain after the effects of local anesthetic have cleared. She/he can resume a light diet, returning to normal in 24 hours; constipation may be a problem. With return home within a few hours after the operation, the patient is up and around but requires more rest for the next week. Patients return to work from within a few days to 2 weeks after surgery.

Inguinal Hernias

Diagnosis

In Case 2, we are presented with a man who has had a long history of groin and associated scrotal mass. Diagnosis of an inguinal hernia is a simple matter when given a history of an inguinal bulge felt or seen, especially if it is a new discovery and if it disappears when supine, as in Case 2. This young man should be examined while he is standing, with unclothed lower body. Seat yourself before him, ask him to strain or cough, and watch the hernia roll down the inguinal ligament and into the upper scrotum. Then see if gentle upward pressure with your or the patient’s fingers can reduce the hernia; if not, have him lie down, and try again. When examining a standing male patient without an obvious bulge, the examiner’s finger pushes up through the upper scrotal skin and is placed against the external inguinal ring. As the patient strains and coughs, a soft mass coming out through the ring and pushing your finger away gives you the diagnosis of a hernia. If the hernia is continuously bulging and will not reduce with position change or gentle upward pressure, surgical referral is indicated without delay (see Algorithm 27.4).

Examination of females also is best done with the patient standing, but invagination of labial skin is next to impossible. One also desires to assess whether this is an inguinal or femoral hernia, which can be difficult (see Algorithm 27.1). Whether a hernia is even present also

27. Groin Hernias and Masses, and Abdominal Hernias 487

Inguinal

Algorithm 27.4. Decision tree for inguinal hernia and inguinal pain.

may be especially difficult to decide in females and in any obese male. On occasion, the examiner will admit uncertainty and recommend follow-up exam or examination by another physician (see Algorithm 27.4). Operating and finding no hernia to repair is to be avoided.

Pain upon straining or lifting but with no appreciable bulge can be the first evidence of inguinal hernia. The groin lump may appear some days later after discomfort from muscle disruption and after inflammation in the muscle have subsided. Pain from inguinal hernia can be poorly or well localized by the patient. Discomfort usually is intermittent and related to prolonged standing or walking or increased intraabdominal pressure. “Burning,” “dragging feeling,” and “ache” all have been used as descriptions. Persistent pain and groin mass suggest incarceration, which requires urgent surgical treatment. Fever, nausea and vomiting, rapid heart rate, marked tenderness over the mass, and abdominal distention must bring to mind likely bowel ischemia, “strangulation,” and the required emergency treatment.

Surgical Treatment of Inguinal Hernia

Open Repair: Open repair is the term used to differentiate from a laparoscopic technique. The open repair can be via an anterior approach or via an approach from behind the inguinal canal, through the preperitoneal space, termed “preperitoneal approach.” Many hernia repair techniques have been described. General surgeons know

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multiple methods. The Italian surgical genius Bassini developed an elaborate anterior open and successful operation using layers of native tissue.1 The modern, currently most popular and successful open anterior technique with native tissue is the Canadian Repair developed at the Shouldice Clinic.2 This features local anesthesia and very early ambulation, after a repair utilizing running stitches in several layers of tissue. Nyhus3 is given credit both for promoting an understanding of the surgical anatomy above the pelvis and for demonstrating advantages in hernia repair with a preperitoneal approach. Lichtenstein4 opened the mesh repair floodgates with his introduction of a highly successful open, anterior technique using inert mesh laid onto the posterior inguinal canal, repairing a hernia without the tension caused by bringing tissues together with stitches. Repairs then were developed that featured mesh placed in the preperitoneal space and repairs in which mesh is used both in that space and over the floor of the inguinal canal. Laparoscopic repairs also have evolved.

The young man in Case 2 had his hernia diagnosed through the history and the exam method described earlier. Many repair techniques could be used. With the expected small opening at the internal ring and the congenital-type indirect inguinal hernia, the sac could be ligated high or stitched, with redundant sac tissue excised, or the sac could be dissected high and inverted. A few stitches taken medially to tighten the internal ring (the Marcy repair) might suffice in a case with firm layer of transversalis fascia in Hesselbach’s triangle. A mesh plug could be used in the internal ring. After an internal ring plug is placed, onlay of mesh covering the inguinal canal provides some insurance against recurrence. The normal postoperative course is similar to the course after femoral hernia repair. However, lifting more than 35 pounds and heavy work are to be avoided for 6 postoperative weeks.

Pitfalls and Perils of Open Inguinal Hernia Repair: Complication rates vary from minimal to 20%. Nerve entrapment or neuroma with virtually constant pain, bleeding and large hematoma, ischemic orchitis, vas deferens injury, intestinal injury, or failure to recognize pregangrene all are known and relatively unusual, but feared. Pain after surgery has been reduced markedly by using a tension-free procedure combined with local anesthesia. Mesh sheets shrink 20% in size. Mesh plugs shrink up to 70% in volume, harden, and may allow a hernia to develop adjacent to the plug. Patient-related complications are ileus, nausea, cardiac, and respiratory. Other complications that can follow hernia

1 Wright AJ, Gardner GC, Fitzgibbons RJ Jr. The Bassini repair and its variants. In: Fitzgibbons RJ, Greenberg AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott, 2002:105–114.

2 Bendavid R. The Shouldice repair. In: Fitzgibbons RJ, Greenberg AG, eds. Nyhus and Condon’s hernia, 5th ed. Philadelphia: Lippincott, 2002:129–138.

3 Nyhus LM, Condon RE, Harkins HW. Clinical experiences with preperitoneal hernia repair for all types of hernia in the groin: with particular reference to the importance of tranversalis fascia analogs. Am J Surg 1960;100:234–244.

4 Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery, including a new concept, introducing tension-free repair. Int Surg 1986;71:1–4.

27. Groin Hernias and Masses, and Abdominal Hernias 489

repair include chronic pain, testicular atrophy or ejaculation abnormality, wound seroma or infection, hydrocele, and scrotal or retroperitoneal hematoma. Recurrence of hernias after surgical repair is of major concern to surgeons and patients alike. Many patients are not closely followed, and many with a recurrence seek aid elsewhere, making recurrence rates difficult to establish. In summary, all of the open approaches now in popular usage have acceptable rates of longterm hernia cure when the reports of centers with large numbers of repairs are reviewed.

Laparoscopic Inguinal Hernia Repair: Laparoscopic repair requires general anesthesia, has been controversial, and is not widely used. However, recent reports of highly acceptable recurrence rates, lessened postoperative pain, and rapid return to regular work have caused genuine increasing interest, demonstrated in a recent compilation of prospective, randomized trials comparing open and laparoscopic repairs (Table 27.1).

Pitfalls and Perils of Laparoscopic Repair of Inguinal Hernias: While some surgeons have excellent reported results, laparoscopic repair has had numerous complications related to this technique, in addition to the usual list of potential complications of open hernia surgery. These include bleeding in the retroperitoneal space, in the abdominal wall, or inside the abdomen; intraabdominal intestinal or artery injury; bladder perforation; trocar-site hernia; stapling a nerve; and small-bowel obstruction. Recurrences have resulted from inadequate mesh fixation, too small a mesh, missed hernia, and mesh displacement. Cost of repairing a hernia with a laparoscopic method is greater than the costs associated with other methods.

Watchful Waiting

Whether watchful waiting is ever indicated is controversial, and the conventional approach is to plan repair when a hernia is diagnosed. The conventional approach is being questioned, however, in asymptomatic hernias. Somewhere between one-half and three-quarter million hernias are operated upon yearly in the United States. It is estimated that an even larger number are not operated upon because individuals are not choosing to have them repaired. Most surgeons recommend repair in order to avoid the higher complication rate and the greater difficulty of repair in cases of incarceration or strangulation, and because of the belief that incarceration/strangulation are likely to occur, when in fact this may be unlikely. Also, long-term complications, including chronic pain, may follow surgical repair. Data are insufficient now to develop clear indications for watchful waiting. An inguinal hernia that is asymptomatic, has a large defect or almost no bulge at all, and that reduces quickly with the patient supine should be able to be observed for some period of time. Also, with a patient who presents with possible incarceration of a hernia that you find to be easily reduced with very gentle pressure, surgical intervention can be delayed for a few hours and, in some cases, for 1 or 2 days.

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Table 27.1. Prospective randomized trials comparing laparoscopic and open repairs (level I evidence).

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Table 27.1. Continued

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Table 27.1. Continued

TAPP, transabdominal preperitoneal approach; IPOM, intraperitoneal onlay mesh repair; TEP, totally extraperitoneal approach; PTEE, polytetrafluoroethylene.

*, Statistically significant.

a Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled, clinical study of laparoscopic vs open tensionfree inguinal hernia repair. Surg Endosc 1998;12:979–986.

b Zieren J, Zieren H, Jacobe CA, et al. Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldice’s operation. Am J Surg 1998;175:330–333.

c Liem MSL, Van Der Graff Y, Van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541–1547.

d Champault G, Rizk N, Catheline JM, et al. Inguinal hernia repair: totally pre-peritoneal laparoscopic approach versus Stoppa operation, randomized trial: 100 cases. Hernia 1997;1:31–36.

e Kald A, Anderberg B, Carlsson P, Park PO, et al. Surgical outcome and cost-minimization analyses of laparoscopic and open hernia repair: a randomized prospective trial with one year follow-up. Eur J Surg 1997;163:505–510.

f Bessell JR, Baxter P, Riddell P, Watkin S, et al. A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure. Surg Endosc 1996;10:495–500.

Source: Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.

Abdominal Wall Hernias

Ventral hernias are those protruding through the anterior wall of the abdomen. Umbilical hernias are ventral, but they are placed in their own category because etiology and repair techniques are so different from those used for ventral incisional hernias. With a weakened area of the wall or with significant increased intraabdominal pressure, hernia develops. At the umbilicus, hernia usually is congenital, but hernia can follow childbirth, increased weight, or be at the upper or

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Table 27.1. Continued

g Wright DM, Kennedy A, Baxter JN, et al. Early outcome after open versus extraperitoneal endoscopic tension-free hernioplasty: a randomized clinical trial. Surgery (St. Louis) 1996;119:552–557.

h Tschudi J, Wagner M, Klaiber C, Brugger JJ, et al. Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Surg Endosc 1996;10:845–847.

i Barkun JS, Wexler MJ, Hinchey EJ, Thibeault D, et al. Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial. Surgery (St. Louis) 1995;118:703–710.

j Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy. Am J Surg 1995;169:84–90.

k Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomized prospective trial. Lancet 1994;343:1243–1245.

l Payne JH, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994;129:973–981.

Source: Reprinted from Scotl DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.

lower end of a healed incision (an incisional umbilical hernia). Preperitoneal fat, omentum, or gut may protrude, causing a bulge, symptoms of pain, and nausea. A huge umbilical hernia may allow a large portion of bowel to enter the sac, to become twisted and compromised, and to perforate. Some umbilical hernias can be repaired using local anesthesia, but most require general anesthesia and muscle relaxation. Asymptomatic hernias may be able to be controlled with an abdominal binder. Symptomatic umbilical hernias are repaired by incising halfway around the umbilical skin, dissecting down to the

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fascia, separating the overlying skin from the hernia sac, separating the fascial ring from the sac, reducing the sac and contents, and closing the fascial defect with permanent suture. A piece of prosthetic mesh often is placed just under the fascial closure, held in place with one or more of the closure stitches.

Epigastric hernias occur in the upper abdomen through a defect in the linea alba and are repaired with simple closure with permanent suture, often buttressed with a piece of mesh in the preperitoneal space. Abdominal wall mass differential diagnosis includes metastatic cancer at the navel (“Sister Mary Joseph” tumor) or dermal metastasis, varicose veins (umbilical, secondary to portal hypertension), lymph node groin mass encroaching onto the abdominal wall, rectus sheath hematoma (usually in an anticoagulated patient: the hard, tender mass is confined to one entire rectus sheath), and desmoid tumor. Desmoids are seen in patients with familial polyposis syndrome and, although benign, can be a problem and difficult to remove surgically. Biopsy is diagnostic, and imaging studies aid in management decision.

Incisional hernias may be small or large and enlarging. Huge symptomatic hernias in an obese patient can be very difficult to repair, carrying the risks of intestinal injury (while freeing adhesions in the abdomen) and of major pulmonary, cardiac, and wound complications postoperatively. Numerous operations have been developed. Almost all repairs used today involve the use of mesh placement somewhere. (For more information, see the chapter “Hernias and Abdominal Wall Defects” by D.J. Scott and D.B. Jones in Surgery: Basic Science and Clinical Evidence) edited by J.A. Norton, et al, published by Springer-Verlag, 2001.) Of particular interest for repair of large and complex incisional hernias are techniques using a giant piece of mesh. The newer laparoscopic methods seem promising, with fewer reported complications and less pain postoperatively.

Other Abdominal Hernias

In a spigelian hernia, fat or an intestinal loop comes through a weak point in the lateral posterior rectus sheath at the semilunar line (in the lower abdomen). This hernia is in the abdominal wall between muscles and fascia, which makes the hernia difficult to locate. It usually is reducible, but it is intermittently painful. Laparoscopic repair works well for these, as does an incision directly onto the palpable lump or through the midline. When a midline incision is used, the site of the abdominal wall is lifted up so that the opening can be seen from underneath and the hernia defect repaired.

In a lumbar hernia, a posterior-lateral bulge is noted, possibly following trauma, through one of the two muscular lumbar triangles. Pelvic floor hernias are rare, and a computed tomography (CT) scan is useful for diagnosis and in planning the operative approach. Parastomal hernias usually develop alongside a colostomy, but they can occur next to an iliostomy. These are common and may require correction, but the recurrence rate is high.

27. Groin Hernias and Masses, and Abdominal Hernias 497

Congenital and Diaphragmatic Hernias

Infants born with congenital diaphragmatic hernia constitute a pediatric and pediatric surgical emergency. While prenatal diagnosis with ultrasound and prenatal treatment is desirable, when not done, a rapid postnatal diagnosis can be crucial. The child has a huge opening in the posterolateral diaphragm (foramen of Bochdalek), the abdominal contents are up in the chest; the child has a scaphoid abdomen, and may have easily heard bowel sounds in the chest. After an abnormality is noted in the child’s breathing and a rapid chest radiograph is ordered, one often can make the diagnosis from seeing gut in the chest and a shift of the mediastinum. A very small amount of contrast put through a tiny nasogastric tube should help clarify the diagnosis. With rapid diagnosis and appropriate treatment (neonatal intensive care before and after surgical correction), formerly high mortality rates have been reduced to acceptable levels.

A sliding hiatal hernia (widened esophageal hiatus with part of the stomach in the chest) exists in almost all patients with gastroesophageal reflux disease. Wrapping some upper stomach around the esophagogastric junction and holding it there with stitches (Nissen repair) has excellent results in those requiring surgical intervention. This procedure lends itself well to a laparoscopic approach, with rapid return home and to work. Preoperative evaluation includes manometry and endoscopy.

In a paraesophageal hiatal hernia, the gastric fundus herniates up through the diaphragm and is superior to the location of the most distal point of the esophagus. Reflux symptoms, possible mild or severe pain, and even gangrenous changes in the herniated portion of the stomach can result. A lateral chest radiography usually is diagnostic; an upper gastrointestinal study always is. If at all symptomatic, a paraesophageal hernia always should be corrected surgically without delay.

Traumatic hernia through the diaphragm always requires repair.

Summary

Evaluation of a suspected or definite groin mass and evaluation of groin pain can be a challenge to any primary physician. History and physical examination, while keeping the different etiologic possibilities in mind, frequently clarify the diagnosis. The most commonly performed general surgical procedure is groin hernia repair. General surgeons are referred for many patients with groin area pains of all types. Almost all patients with groin mass or groin pain are, sooner or later, referred to a surgeon. The sooner this is done, the better.

The transition in hernia surgery to widespread use of local anesthesia and rapid return to home and normal activities has been aided by shorter operating times and use of some type of inert, nonabsorbable mesh. Outcomes and patient satisfaction have improved. Types of hernia repairs and their pros and cons have been presented, along with discussion of definitions, differential diagnoses, and anatomic and

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special considerations. Abdominal wall hernias as well as congenital and diaphragmatic hernias have been briefly discussed.

Selected Readings

Bendavid R. Complications of groin hernia surgery. Surg Clin North Am 1998;78(6):1089–1103.

Cunningham J, Fry DE, Richards AT, et al. Part IV: complications of groin hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott, 2002:279–324.

Felix E, et al. Causes of recurrence after laparoscopic hernioplasty. A multicenter study. Surg Endosc 1998;123:226–231.

Gilbert AI, Graham MF. Tension-free hernioplasty using a bilayer prosthesis. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott, 2002:173–180.

Hair A, et al. What effect does the duration of an inguinal hernia have on patient symptoms? J Am Coll Surg 2001;193:125–129.

Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery, including a new concept, introducing tension-free repair. Int Surg 1986;71:1–4.

Loham AS, et al. Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg 1997;225(4):422–431.

Neuhauser D. Elective inguinal herniorrhapy versus truss in the elderly. In: Bunker JP, Barnes BA, Mosteller F, eds. Costs, Risks and Benefits of Surgery. New York: Oxford University Press, 1977:223–239.

Nyhus LM, Condon RE, Harkins HN. Clinical experiences with preperitoneal hernia repair for all types of hernia in the groin: with particular reference to the importance of tranversalis fascia analogs. Am J Surg 1960;100:234–244.

Payne JH, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994;129:973–981.

Scott DJ, Jones BJ. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001:727–823.

Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for primary inguinal hernia: results of 3,019 operations from five diverse surgical sources. Am Surg 1992;58:255–257.

Stassen, et al. Reoperation after recurrent groin repair. Ann Surg 2001;234: 122–126.

Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1984;13:545–554.

Wantz GE. The Canadian repair: personal observations. World J Surg 1989; 13:516–521; J Am Coll Surg 2000;190:645–650.