BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE & ADDRESS / DR. BALAJI. H
P G STUDENT IN GENERAL SURGERY
BMC&RI, BANGALORE, KARNATAKA
2 / NAME OF THE INSTITUTION / BANGALORE MEDICAL COLLEGE & RESEARCH INSTITUTE,KR ROAD, FORT, BANGALORE-560002
3 / COURSE OF STUDY AND SUBJECT / M.S. IN GENERAL SURGERY
4 / DATE OF ADMISSION TO THE COURSE / 29.05.2013
5 / TITLE OF TOPIC / “A STUDY OF THE CLINICAL PROFILE AND TREATEMENT MODALITIESOF VENTRAL HERNIA IN TERTIARY CARE HOSPITAL.”
6. / BRIEF RESUME OF INTENDED WORK:
6.1Need for study:
Ventral hernias comprise the second most common hernia presentations in the surgical speciality Among the ventral hernias, incisional hernia were found to be most common 5to 11% of patients subjected to abdominal operations. Further incisional hernias are common due to surgical cause & gynecological surgeries ,ventral hernias were more commonly seen in middle age group & in females ,multiparity,& obesity, are most common associated factors As ventral hernia is one of the very common conditions presenting to our hospitals, there is a need to study the disease to know the various presentation, to gauge the awareness levels of the patients coming to us and also to determine the best modality of treatment in our set-up. Thus, the study is being done to know,the occurrence of ventral hernias with special relation to age, sex, pre-disposing factors, various modes of presentation, risk factors for the development of ventral hernias.
- Various treatment options currently available & the changing trend.
- Post operative complications of hernia repair & their management
Jayanth Sharma9et al in their study have stated that incisional hernia occurring through Maydl et al used a technique which well high approached present day standards. He dissected out the various musculo-fascial layers and repaired them separately.
Koontz3 and Throckmorton4 et al introduced tantalum gauze. These foreign materials had the disadvantage of metal fatigue with subsequent fragmentation, sinus formation and perforation of bowel with fistula consequent to fragment penetration
Judd5 and Gibson6et al both described repair technique based on extensive anatomic dissection of the scar and adjacent tissues. Fascia lata grafts used in the form of strips or sheets were first reported by Mc Arthur7 et al. Mair et al advocated the use of skin in sheets or strips. However these tissues tends to get absorbed and were associated with high recurrence rates.
The modern era of prosthetic hernia repair began when Usher.F.C8 et al reported his experience with polyethylene (marlex) mesh. Later polyamide (nylon) mesh and recently PTFE ( Polytetra fluoro ethylene ) were introduced. These three materials have revolutionized the surgery of incisional hernia.
Lichtenstein10et al reported that monofilament polypropylene stimulates a strong fibroblastic response and has a marked resistance to infection.In general Primary Anatomical repair of Incisional hernias can be performed for hernia defects less than 4 cm in diameter with strong, viable surrounding tissue11,recurrence rate (31-49%).
Comparative studies conducted by K. Cassar and A. Munro12 et al for surgical treatment of Incisional hernia concluded that Open Suture repair for Incisional hernia carries a high.
Epigastric hernia first described by Villenuve in the year 1285.The first sucessful repair was done by Maunior in 1802.2,3
According to Stoppa .R et al ,J Am Coll Surg 2005 ,there is biomechanical advantage to placing mesh in the retro-myofascial plane for repair of ventral abdominal hernias. Intra-abdominal pressure applied to the periphery of the mesh increases apposition to the abdominal wall rather than causing distraction and this translates, in general, into lower recurrence rates than after "inlay" and "onlay" mesh placement. 7,8,9
Use of biological mesh versus standard wound care in infected incisional ventral hernias,the SIMBIOSE study: a study protocol for a randomized multicenter controlled trialMariette C et al.Pub Med , 2013 may 7:14(1):131
Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitoneal Gore-Tex mesh: prospective study and review of the literature.JLaparoendosc Adv Surg Tech A. 2002 Aug;12(4):263-7. Review.PMID: 12269494[PubMed - indexed for MEDLINE]
Long-term outcomes in laparoscopic vs open ventral hernia surgery. World Journal of Laparoscopic Surgery, May-August 2008;1(2):32-35
Hernia: The protrusion of any organ (tissue) as a whole or part out of its boundary through an anatomical or acquired weak spot.. A hernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding wall.2 Hernias are among the oldest surgical challenges which have confronted the surgical community. The Egyptians (1500 B.C),the Phoenicians (900 B.C),and the ancient greeks (Hippocrates 400 B.C) diagnosed hernia during their times. The word Hernia is derived from the latin word for rupture. In Greek word hernia means a bud or an offshoot, a budding or a bulge. Hernia also means tear in Latin literature.3Celsus (AD 40) an ardent follower of Hippocrates , also known as the Latin Hippocrates documented Roman surgical practice that is taxis was employed for strangulation. Truss and bandage could control reducible hernia.4
Ventral Hernia : Are those hernias which occur through the anterior abdominal wall.2These defects can be categorized as spontaneous or acquired or by their anatomical location on the abdominal wall.2
- EpigastricHernia :
II. Umbilical Hernia :
Umbilical hernias occur at the umbilical ring and may either be present at birth or develop gradually. Umbilical hernias are present in approximately 10% of all newborns and are more common in premature infants.5 Omphalocele (Body wall defects) involves herniation of abdominal viscera through an enlarged umbilical ring. The origin of the defect is a failure of the bowel to return to the body cavity from its physiological herniation during the 6th to 10th weeks of gestation.5The first references to umbilical hernia is in the Egyptian papyrus of Ebers (circa1552 B.C) but the first formal description of umbilical hernia comes from the writings of Hindu Physician Charakain A.D.1 or earlier.The first recorded description of umbilical hernia repair comes from Albucasis-Abul Qasimal Zahrawi, the great Moorish surgeon (A.D.1013-1106). But, credit for the modern surgical treatment of umbilical hernia goes to William. J .Mayo who repaired these defects by overlapping fascia
III. Spigelian hernia:
Spigelian hernias can occur anywhere along the length of the Spigelian line or zone. Where in an aponeurotic band of variable width at the lateral border of the rectus abdominis.5The semilunar line was described by Adrian van Spiegel (Spigelius, 1578-1623).However the hernia that is named after him was first described by Klinkosch in1764.
IV. Incisional Hernia(Postoperative hernia) :
Aproximately 4 million abdominal surgeries are performed every year and as many as 10 to 20% of these patients have been estimated to develop hernias at the abdominal incision site. Hernia may depelop through slow architectural deterioration of muscular aponeurosis or they may develop from failed healing of an anterior abdominal wall incision called incisional hernia.5Gerdy repaired an incisional hernia in 1836 .He inverted the entire sac includingthe skin and sutured the margins of the aperture together Madyl in 1886 repaired an incisional hernia by identifying the musculo-aponeurotic layers and closed them in layers.6
6.3 Objectives of the study:
1)To study ventral hernias with respect to the various anatomical sites and various clinical presentation.
2)To study the various risk factors and complications of different types of ventral hernias.
3)To study clinically the various forms of ventral hernia and the management protocol.
MATERIALS AND METHODS:
7.1.Source of data:
Patients with a diagnosis of ventral hernia, being admitted in the department of General Surgery, in Bowring and lady Curzon and Victoria hospitals Bangalore.
7.2. Materials and Method of collection of data (including sampling procedure, if any)
Definition of a study subject:
100 cases of ventral hernias admitted in the department of General Surgery, in Bowring and lady Curzon hospital and Victoria hospitals Bangalore,will be included in the study. The patients are then taken up for surgery after informed/written consent. The patients are given a choice to choose the surgical procedure. The findings are recorded and the patients are monitored post-operatively and followed up for a period of one year after discharge. Data collected is then analyzed.
Inclusion criteria:
1)Patients with ventral hernias admitted to the Department of Surgery, in Bowring and lady Curzon Hospital & Victoria hospitals Bangalore.
Exclusion criteria:
1) Debilitated elderly patients with severe COPD & major cardiac disease.
2) Morbidly, Obese, BPH, Metabolic Disease, Ascities, paediatric age group below 14 year
Sample size: Minimum 100 cases study.
Statistical analysis: A suitable statistic method will be applied.
7.3 Does the study require any investigation to be conducted on patients or animals specify?
Yes, routine investigations will be conducted on patients for assessment of their fitness for anesthesia and surgery. The following investigations are necessary :
- Hemoglobin% , white blood cell count, differential count (polymorph nuclear cell count), erythrocyte sedimentation rate, platelet count, bleeding and clotting time and blood group.
- Random blood sugar and renal function test.
- Chest X-ray
- HIV and HBs Ag
- ECG (where applicable)
- Ultrasound Abdomen and pelvis
- Computed tomography (where applicable)
7.4Has the ethical clearance been obtained from ethics committee of your Institution in case of 7.3?
“YES”. Theethical clearance has been obtained from the ethicscommittee of Bangalore Medical College and Research Institute, Bangalore.
LIST OF REFERENCES:
1) Mark. A, Malangoni and Michael J. Rosan; “Hernias”. Sabiston Textbook of surgery, 18thedition;Elsevier, 2008 Volume 2 :1173-1174.
2) Patrick J Javed and David c. Brooks, “Hernias”; Maingot’s Abdominal Operations,
11th Edition, MacGraw Hill ; 2007:133-138.
3) Koontz AR. Preliminary report on the use of tantalum mesh in the repair of ventral hernia. Ann of Surg 1998; 127: 1079.
4) Throckmorton TD. Tantalum gauze in the repair of hernia and complicated by tissue
deficiency, Surg ; 1998: 23:32.
5) Judd ES. The prevention and treatment of ventral hernia. Surg Gynecol Obstet, 1912; 14: 175.
6) Carbajo MA, Martpdel, Olmo JC, Blanco JL. Laparoscopic approach to incisional
hernia. Surg Endoscopy 2003; 17(1): 118-22.
7) Mc Arthur LL. Autoplastic suture in hernia and other diastases- Preliminary report.
JAMA 1901;37:1162.
8) Usher FC, Oschner J, Tuttle LLD Jr. Use of marlex mesh in the repair of Incisional
hernia. Am J Surg 1958; 24: 969.
9) Jayant Sharma. Prolene meshplasty in hernia repair. Br J Surg 1997; oct:289-92.
10) Lichtenstein IL, Shulman AG, Amid PK. Twenty questions about hernioplasty.
Am Surg 1991; 57: 730-3.
11) Neal E. Seymour and Robert. L. Bell; “Abdominal Wall, Omentum, Mesentery &
Retroperitoneum” Schwartz’s Principles of Surgery 9th edition; Mc Graw Hill, 2010:1273-1274.
12) Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg 2002; 89(5):
534-45.
13) Andrew N. Kingsnorth, Giorgi Giorgobiani and David H. Bennett, “Hernias,Umbilicus & Abdominal Wall”. Bailey and Love’s Short Practice of Surgery 25th edition, Arnold International ; 2008: 987-988.
14) Read RC. The Development of Surgical hernioraphy; Surgical clinics of NorthAmerica 1984; 64:185 – 196
15) CA Courtney, AC Lee, C Wilson and PJ O'Dwyer. Ventral hernia repair: a study of current practice. Hernia. 2003; 7(1): 44-46.
16) Wantz GE. Abdominal wall hernias. In: Schwartz principles of surgery, 9thed. McGraw Hill, 2008; 1585-1611.
17) Flament.B.J, Palot.P.J. Prosthetic repair of massive Abdominal ventral hernias inNyhus and Condons Hernia.5thedn; Philadelphia 2002; 31: 341 – 365.
18) Nyhus and condon’s et al, Hernia 4th edition, Lippincott Williams and wilins2002 : 389.
19) Romanel G.J. The anterior abdominal wall, cunningham’s manual of practical anatomy, 15th edition, 1986; 91-103.
20) Read RC “Milestones in the history of hernia surgery prosthetic repair” hernia 2004:8(1);8-14
21) Courtney C A, Lee A C, wilson C, et al,Ventral hernia repair: a study of current practice, hernia 2003;7(1);44-6
22) Franklin ME jr.Gonazaez JJ Jr, Glass Jlet al. laproscopic ventral and incisional hernia repair;an 11 year experience hernia 2004; 8(1);23-7.
23) Santra TA and Roslyn J.J , Incisional Hernia, Surg Cln N Am,1993;73:557-570
7.
8.
9 /
SIGNATURE OF CANDIDATE
10 /REMARKS OF THE GUIDE
/ There is a need for this study as ventral hernias are common surgical problems in day to day surgical practice. This study will reveal the occurrence of ventral hernias & clinical presentations & outcome of various modalities of management.11 /
NAME AND DESIGNATION
11.1 GUIDE / DR.H.R.HARINDRANATH. MBBS, MSASSOSIATE PROFESSOR ,
DEPT OF GENERAL SURGERY.
11.2SIGNATURE
11.3CO-GUIDE(IFANY)
/ -NIL-11.4SIGNATURE
11.5 HEAD OF THE DEPARTMENT
/ Dr. T.DURGANNA.MBBS, MSPROFESSOR AND HOD,
DEPT OF GENERAL SURGERY,BMC & RI.
11.6 SIGNATURE
12 /12.1 REMARKS OF CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE
ANNEXURE 1
INFORMED PATIENT’S CONSENT
Patient’s IP No: ______
I ______s/o, w/o, d/o, ______
Age ______years, Sex (Male/Female) ______, have been explained in detail in my own language about the study ‘“A STUDY OF THE CLINICAL PROFILE AND TREATEMENT MODALITIESOF VENTRAL HERNIA IN TERTIARY CARE HOSPITAL.”thatis being carried out in BMCRI, Bangalore
I have no issues about sharing patient details in case records and would cooperate for the study.I have been informed that I shall not be sharing any incentives .I understand in this study personalidentity will not be revealed, but data can be used for publication/dissertation purpose.
During the study there has been no compulsion and hence the willingness to take part in the study is completely voluntary. I shall not hold the hospital doctors or the institution responsible for any untoward effect.
Place: Bangalore
Date: Signature / Left Thumb Impression
of the patient
1