Issues in the Pelvic Region

Educational Objectives

The goal of this program is to improve the management of pelvic conditions. After hearing and assimilating this pro­gram, the clinician will be better able to:

Review the advantages of conventional open repair of hernia with mesh.

Discuss the results of the Veterans Affairs hernia trial.

Recognize when to utilize diagnostic peritoneal lavage vs ultrasonography in a patient with pelvic
fracture.

Describe treatment options for condyloma acuminata.

Discuss the role of vaccination in preventing human papillomavirus infections.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Drs. Neumayer and Maier were recorded at the 37th Annual Postgraduate Course in Surgery, held April 17-19, 2008, in Charleston, SC, and sponsored by the Department of Surgery, Medical University of South Carolina. Dr. Luchtefeld was re­corded at the 19th Annual International Colorectal Disease Symposium, held February 14-16, 2008, in Fort Lauderdale, FL, and sponsored by Cleveland Clinic Florida. The Audio-Digest Foundation thanks the speakers and the sponsors for their coop­eration in the production of this program.  

What is the Best Way to Fix an Inguinal Hernia? The Data

Leigh A. Neumayer, MD, MS, Professor of Surgery, University of Utah School of Medicine; Co-Director, Inte­grated Breast Program, Huntsman Cancer Institute, Salt Lake City, UT

Introduction: according to speaker, all primary hernias should be repaired conventionally (with mesh), and all recur­rent hernias probably should not be repaired conventionally, but definitely with mesh

Conventional hernia repair: if performing tissue repair, data support only Shouldice repair; evidence from Co­chrane database review in 2001 that use of open mesh repair associated with 50% to 75% reduction in risk for re­currence; some evidence of faster return to work and lower rates of persisting pain after mesh repair; arguments for conventional open repair  —  easy technique to learn; does not require general anesthesia; pain and time to return to work relatively equivalent (ie, no large differences between groups) whether open mesh repair or laparoscopic mesh repair used; pain differences disappear by 3 mo; excellent results across different types of practices

Veterans Affairs (VA) hernia trial

Background: »2200 participants; 2 groups (laparoscopic vs open repair); groups evenly matched; patients previ­ously stratified (based on recurrence of hernia [»10% of hernias recurrent]); no American Society of Anesthesi­ologists (ASA) class 4 patients enrolled; one-third of participants ASA class 1; strict criteria about who could perform repair; operative times similar in both groups; 2-yr follow-up

Results: overall, open hernia repair associated with lower recurrence rate than laparoscopic repair (for primary her­nias, 4% in open group vs 10% in laparoscopic group); learning curve  —  in highly experienced surgeons, recur­rence rate for laparoscopic repair, 10% to 15% (after >250 repairs reached, recurrence rate drops); for surgeons with >250 repairs, recurrence rate of laparoscopic repair equivalent; if surgeon not highly experienced, recur­rence rate higher with laparoscopic repair; other influential factors  include surgeon’s experience, surgeon’s age, length of operation, and hospital performance record; distinction between surgeons <45 yr of age and those >45 yr of age (surgeons <45 yr of age had less problem with repair, probably because they performed more laparo­scopic repairs during residency); dichotomous relationship between age of surgeon and recurrence; recurrence rates with different mesh repairs ranged from 0% to 6%; more years in residency, lower the rates of recurrence; laparoscopic repair more variable, based on attending surgeon; in most cases, inguinal hernia repair performed with local anesthesia and intravenous sedation; speaker recommends Lichtenstein procedure

Pain after surgery: significant difference between groups; laparoscopic group better on day of surgery and at 2 wk (based on patient daily pain diaries); return to normal activities differed by 1 day; return to sexual activity similar in both groups; more patients in laparoscopic group able to perform specific activities at 2 wk; at >3 mo, differ­ences not apparent

Informed consent for open repair: provide patient with real recurrence rate (»4% for repair of primary hernia and at least double for repair of recurrent hernia); chronic pain after hernia repair occurs in 6% to 13% of patients at >3 mo; provide patient with alternative (watchful waiting); study showed that »25% of patients on watchful waiting re­quire repair in »4 yr (usually due to pain; low number of hernia accidents); English study concluded that all hernias should be repaired because 2 patients had postoperative complications (myocardial infarction and stroke; patients initially in watchful waiting group, then had repair because of pain)

Large scrotal hernias: difficult to achieve success with any repair; consider watchful waiting (unlikely to strangu­late); patients often have other significant comorbidities; if repair attempted, large sections of mesh likely needed

Recurrent hernia: no data supporting any particular approach; trend toward supporting use of posterior repair, espe­cially if first repair anterior; posterior repair can be done via laparoscopic or open approach; no large body of evi­dence for open anterior approaches that involve posterior placement of mesh (eg, Kugel repair or prolene hernia system [PHS])

Groin hernia in women: no large randomized trials; women excluded from VA trial, due to difference in anatomy and repair; not necessary to preserve round ligament; not known whether mesh necessary; higher incidence of fem­oral hernia; report from Swedish hernia registry  —  nearly 7000 groin hernia repairs in women; higher proportion of emergent repairs; higher rate of femoral hernias at reoperation for recurrence (42% vs 5%); laparoscopic repair may be beneficial for initial repair to avoid missing femoral hernia

Summary: surgeon should be aware of his or her own results for inguinal hernia repair (only valid, however, if pa­tients followed beyond initial postoperative period); all inguinal hernias in men should be repaired with mesh; open mesh anterior approach appears easier technique to master; laparoscopic repair likely better in women because of issue of missed femoral hernias

Optimal Care of Pelvic Fractures

Ronald V. Maier, MD, Jane and Donald D. Trunkey Professor and Vice Chair, Department of Surgery, Univer­sity of Washington School of Medicine; Surgeon-in-Chief, Harborview Medical Center, Seattle

Introduction: pelvic fractures most commonly caused by motor vehicle accidents; due to safety improvements made to motor vehicles, anteroposterior (AP) pelvic injuries now more likely seen in pedestrians than in automobile driv­ers; patients can die rapidly from pelvic fractures (cause death by exsanguination)

Pelvic fractures: some association between severity of pelvic fracture and pattern, but association not absolute; pneumatic antishock garments (PASG) no longer used; air splint stabilizes pelvis and lower extremities for trans­port; method of intervention determined by patient’s physiology; diagnostic peritoneal lavage (DPL) standard pre­viously, but ultrasonography (US) becoming more popular; advantage of US ability to repeat as often as desired; if evidence of intra-abdominal bleeding and US negative, repeat US or perform DPL; with DPL, concern that when bleeding present, surgeon will go through hematoma that is dissected extraperitoneally and end up with false-posi­tive result; study  —  300 participants; DPL performed; only 2 false positives seen

Intestinal injury: often associated with pelvic fractures; US suboptimal for intestinal injuries (although good for de­tecting fluids in quadrants in pelvis and possibly in solid organ injury); such intestinal injury more likely detected by DPL; interventional radiology (IR) becoming increasingly available, and preferable to orthopedic stabilization according to speaker (assuming both available in institution); stabilization  —  bed sheet useful (fits all patients and pressure easily adjusted); C-clamp no longer used; external fixator also option; if patient not in shock, computed to­mography (CT) performed; however, if patient not stable, CT should not be used (DPL or US more suitable); man­agement strategy  —  includes surgery and angiography, depending on findings; statistics suggest more patients with pelvic fractures and intra-abdominal bleeding saved by performing surgery before angiography; surgery used as di­agnostic procedure to rule out significant intra-abdominal bleeding before angiography

Safety restraint (ie, lap belt) injury: patients with thoracolumbar fractures and lap belt signs tend to have increased incidence of intra-abdominal injuries; presence of seatbelt sign and flexion-distraction fracture pattern in lumbar spine in child means substantial kinetic energy delivered across intestines (ie, intestines transected); individuals with this pattern have significant incidence of positive DPL (US not of benefit); speaker notes that younger the in­dividual (eg, <15 yr), more likely intestine involved

Urethral injury: second most common occurrence with pelvic fracture; physical signs include high-riding prostate on rectal examination, blood at urethral meatus, hematoma, and resistance to passage of Foley catheter; study showed that if injury present, only 60% of patients had overlapping; 60% had no physical signs of urethral injury; anterior ring injury involving ramus and sacroiliac joint disruption most common associated pelvic injury; delay in repair minimizes complications (first decompress bladder and resolve acute problem); done by suprapubic cystos­tomy; speaker recommends involvement of urology colleague for insertion of Foley catheter

Perineal injury: military experience led to practice of doing diverting colostomy in every patient with groin injury; this practice subsequently determined to be unnecessary; study found that of those who had diversion, 25% became infected (vs 10% of those who did not have diversion); meta-analysis showed infection rates identical with or with­out colostomy; actually less infections without colostomy; if colostomy performed in lower abdomen in patient with anterior perineal injury, patient has as much chance of contamination from colostomy as from intact anus; in true posterior injury with penetration of buttocks, more infections seen in those without colostomy; with significant tissue loss to posterior, colostomy necessary to protect ischemic tissue from becoming infected posteriorly; speaker’s recommendations  —  debride and irrigate, drain anything potentially loculated, with or without colos­tomy, and allow healing by secondary intent; loosely approximate where sphincter torn in half, to minimize gap

Eradicating Condyloma Acuminata

Martin A. Luchtefeld, MD, Assistant Professor, Department of Surgery, Michigan State University, College of Human Medicine; Program Director, Colon & Rectal Residency, Ferguson Clinic, Grand Rapids  

Human papillomavirus (HPV): causes condyloma acuminata; >80 subtypes, one-third of which cause anogenital infections; subtypes 6 and 11 (HPV-6 and -11) most common cause of anogenital warts; HPV-16 most common cause of cervical and anogenital cancers; HPV-18 most common cause of squamous cell carcinoma and most com­mon cause of adenocarcinoma of cervix; most common sexually transmitted disease (incidence, 5.5 million; preva­lence, 20 million)

Treatment: options include no treatment, or medication, surgery, immunotherapy, combination therapy, or preven­tion

Podofilox: purified version of podophyllin (plant resin); typically applied bid for 3 days, then left off for 4 days; cy­cle repeated for 1 mo; not for use in anal canal; irritating and causes discomfort (poor compliance rate); clearance rate, 35% to 80%; recurrence rate, 10% to 20%

Trichloroacetic acid: keratolytic agent plus bichloroacetic acid; applied directly to lesion; disadvantage of requiring multiple office visits for application

Oncologic agents: 5-fluorouracil (5-FU) best known; thiotepa and bleomycin also used; 5-FU as 5% gel applied di­rectly to lesion (irritating to skin)

Immunomodulators: imiquimod (Aldara)  —  leads to local increase in interferon (IFN); irritating to skin; applied 3 times/week for £16 wk; success rate, 50% (recurrence rate, 10%); beneficial as first-line therapy in limited exter­nal disease; IFN alpha-2a  —  injected directly into lesion; response rate >60%; not reasonable option for most pa­tients seen in practice

Autologous vaccine: surgery performed, then deactivated virus from obtained tissue used; patient treated for 6 wk consecutively; good results reported (84% in one study); of limited use, however, due to difficulties with prepar­ing vaccine and regulatory issues

Surgery: not complicated; need only to remove tissue down to level of dermis (no advantage of going deeper); suc­cess rate 60% to 90%; recurrence rate 20% to 30%; role of laser — Bellingham (1982) compared laser surgery to surgical excision and found no difference in healing rates or pain; recurrence rate higher in laser-treated group; another study also found no decrease in recurrence with use of CO₂ laser

Combination therapy: at time of surgery, after removal of condyloma, IFN injected into anal canal; recurrence rate in treated group, 12% (in untreated group, 39%); surgical removal with immunotherapy  —  argon beam plasma coagulator combined with imiquimod; patients who receive imiquimod shown to clear condyloma faster (true whether patients immunocompetent or immunosuppressed); study  —looked at ablation vs imiquimod vs ablation plus medical therapy; recurrence rates based only on patients who obtained complete clearance with therapy (ie, patients who received imiquimod alone not included); recurrence rate at 6 mo with surgery only, 74%, and better with surgery with imiquimod or with imiquimod alone

Condyloma in immunosuppressed: difficult to treat; all treatments less effective than when used in immunocompe­tent patients; study (Ludwig)  —  found that in immunosuppressed, recurrence after surgical excision 66% (27% in immunocompetent); immunosuppressed include transplant and HIV-positive patients (probably good candidates for combined therapy)

Giant condyloma acuminata: Buschke-Lowenstein tumor; most commonly associated with HPV-6 and -11; tends to resemble cancer (locally aggressive and invasive), with high rates of recurrence and malignant transformation; re­cent review found 52 cases in literature (42% condyloma only, 8% carcinoma in situ [CIS], and 50% invasive can­cer on final histology); likely represents spectrum between simple condyloma and squamous cell cancer; relatively rare; treatment  —first choice local excision with 1-cm margin; in series of 52 cases, 7 involved rectum (abdomino­perineal resection performed); in selected cases, Nigro protocol (combination irradiation and chemotherapy) re­portedly successful when local excision not possible

Prevention: all treatments associated with some failure and recurrence; abstinence not realistic; efficacy of condoms uncertain

Quadrivalent vaccine: study (published in New England Journal of Medicine)  —  effective against HPV-6, -11, -16, and -18; >500 participants; vaccine given at day 1, 3 mo, and 6 mo; 3–yr follow-up; results  —  vaccine especially effective in women with no HPV infection at time of enrollment (100% effective in treating any wart and 100% effective in preventing cervical intraepithelial neoplasia [CIN] or adenocarcinoma in situ with vaccine-specific type of HPV); when women with prevalent-type HPV infection included, efficacy still satisfactory, and cases of warts decreased from 83 to 58; evidence seen of prevention of CIN or adenocarcinoma in situ (cases reduced from 155 to 71); when all women and all subtypes included, efficacy less impressive (warts decreased by 34%, and CIN and adenocarcinoma in situ decreased by 20%)

Bivalent vaccine: Costa Rican HPV Vaccine Trial group — large randomized controlled trial; participants positive for HPV; no evidence of increased clearance of virus seen in vaccinated group; consequently, Centers for Disease Control and Prevention recommends only quadrivalent vaccine for all girls at 11 or 12 yr of age

Suggested Reading

Awad SS et al: Improved outcomes with the Prolene Hernia System mesh compared with the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair. Am J Surg 193:697, 2007; Erratum in: Am J Surg 2007 Aug;194:274; Basta AM et al: Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma. J Urol 177:571, 2007; Blackmore CC et al: Predicting major hemorrhage in patients with pelvic fracture. J Trauma 61:346, 2006; Butters M et al: Long-term re­sults of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs. Br J Surg 94:562, 2007; Croce MA et al: Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 204:935, 2007; Eklund AS et al: Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 249:33, 2009; Fränneby U et al: Risk factors for long-term pain after hernia surgery. Ann Surg 244:212, 2006; Friese RS et al: Abdominal ultrasound is an unreliable modality for the detection of hemo­peritoneum in patients with pelvic fracture. J Trauma 63:97, 2007; Kim JJ et al: Health and economic implications of HPV vac­cination in the United States. N Engl J Med 359:821, 2008; Kreuter A et al: 5% imiquimod suppositories decrease the DNA load of intra-anal HPV types 6 and 11 in HIV-infected men after surgical ablation of condylomata acuminata. Arch Dermatol 142:243, 2006; Kuehn BM: CDC panel backs routine HPV vaccination. JAMA 296:640, 2006; Tayal VS et al: Accuracy of trauma ultrasound in major pelvic injury. J Trauma 61:1453, 2006; van Veen RN et al: Randomized clinical trial of mesh versus non-mesh primary inguinal hernia repair: long-term chronic pain at 10 years. Surgery 142:695, 2007; Yallalampalli, Sasi [cor­rected to Yallampalli, Sasi].Zimmerman RK: HPV vaccine and its recommendations, 2007. J Fam Pract 56:S1, 2007.