Results of expanded polytetrafluoroethylene patches in moderate and large incisional hernias

Open Intraperitoneal Onlay Mesh (IPOM) Technique for Incisional Hernia Repair

In an Expert Consensus Guided by Systematic Review the panel agreed that for open elective incisional hernia repair sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. Accordingly, the available literature on the open IPOM technique was searched and evaluated. Material and Methods: A systematic search of the available literature was performed in July 2018 using Medline, PubMed, and the Cochrane Library. Forty-five publications were identified as relevant for the key question. Results: Compared to laparoscopic IPOM, the open IPOM technique was associated with significantly higher postoperative complication rates and recurrence rates. For the open IPOM with a bridging situation the postoperative complication rate ranges between 3.3 and 72.0% with a mean value of 20.4% demonstrating high variance, as did the recurrence rate of between 0 and 61.0% with a mean value of 12.6%. Only on evaluation of the upward-deviating maximum values and registry data is a trend toward better outcomes for the sublay technique demonstrated. Through the use of a wide mesh overlap, avoidance of dissection in the abdominal wall and defect closure it appears possible to achieve better outcomes for the open IPOM technique. Conclusion: Compared to the laparoscopic technique, open IPOM is associated with significantly poorer outcomes. For the sublay technique the outcomes are quite similar and only tendentially worse. Further studies using an optimized open IPOM technique are urgently needed.

Treatment of Large Incisional Hernias in Sandwich Technique - A Review of the Literature

Introduction

In a systematic review of the surgical treatment of large incisional hernia sublay repair, the sandwich technique and aponeuroplasty with intraperitoneal mesh displayed the best results. In this systematic review only the sandwich technique, which used the hernia sac as an extension of the posterior and anterior rectus sheath and placement of a non-absorbable mesh in the sublay position, was included. Other modifications of the sandwich technique are published in the literature and were also analyzed in this literature review.

Methods

A systematic search of the available literature was performed in November 2017 using Medline, PubMed, and the Cochrane Library using the terms “sandwich technique”, “double prosthetic repair”, “double mesh intraperitoneal repair”, and “component separation technique with double mesh”. This review is based on 24 relevant publications. Unfortunately, the evidence of the available studies is not very high since only prospective and retrospective case series have been published. There are no comparative studies at all. Therefore, the findings of the published case series must be viewed in a critical light.

Results

The published studies report a remarkably low recurrence rate of 0-13% with a follow-up of 1–7 years. One limitation that must be mentioned here is that in around half of the studies the method of follow-up was not specified and in the remaining cases this was based on clinical examination by the surgical team. This puts into perspective the reported results, which appear to be too favorable given the complex nature of the hernias involved.

The major disadvantage of the sandwich technique is a very high rate of wound complications of up to 68%, mainly induced by creation of large skin and subcutaneous cellular tissue flaps.

Conclusion

It is difficult to evaluate the significance of the various modifications of the “sandwich technique” based on the available literature since it includes only case series and no comparative studies. The techniques used are associated with very high wound complication rates but with only relatively low recurrence rates despite the complexity of the cases involved. This must be verified in studies with a well-designed methodology.

A systematic review of the surgical treatment of large incisional hernia

PURPOSE

Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair.

METHODS

A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model.

RESULTS

Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6%, recurrence hazard <0.5% per year). Wound complications were frequent and most often seen after complex LIH repair.

CONCLUSIONS

The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.

[How to choose a mesh for the treatment of incisional hernias?]

The incidence of recurrences after raphy for treatment of incisional hernias has been reported as high as 50%. So, the use of a mesh is recommended for reinforcement of the parietal abdominal wall in the management of incisional hernias. Many types of mesh are presently available with different characteristics. The use of a mesh requires to choose the appropriate material, depending on the site of the implantation and the type of performed surgical procedure.