Modifications to Rives technique for midline incisional hernia repair

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

ONLAY VERSUS SUBLAY TECHNIQUES FOR INCISIONAL HERNIA REPAIR: 30-DAY POSTOPERATIVE OUTCOMES

ABSTRACT BACKGROUND: The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. AIM: The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. METHOD: This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. RESULTS: We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. CONCLUSION: Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

Erratum: Addendum: Abdominal Wall Reconstruction: An Integrated Approach

[This corrects the article DOI: 10.1055/s-0038-1667062.].

Three stitch hernioplasty: A novel technique for beginners

Objective:

To analyze mesh fixation with minimum sutures and postoperative complications.

Study Design:

Prospective study.

Place and Duration of Study:

Department of General Surgery, Thanjavur Medical College and Hospital, Tamil Nadu, from July 2010 to June 2012.

Materials and Methods:

All inguinal hernia patients, who fulfilled the sample selection criteria, were admitted and planned for surgery. The prolene mesh is fashioned as in Lichtenstein's repair, placed and fixed only by three prolene stitches. The first stitch is made in the periosteum of pubic tubercle. The second stitch is taken in the inguinal ligament (1.5 cm lateral to the pubic tubercle) and the third stitch is from the medial most part of the conjoint tendon, that is, the mesh is fixed in the medial aspect alone.

Results:

Majority of the patients fall between the age group of 40 and 60 (72%) years and all are male patients. Of the total cases, 50% were right sided, 25% were left sided, and 25% were bilateral. Of the postoperative complications, 12% had seroma, 4% had hematoma, 2% developed surgical site infection, 2% developed chronic groin pain, 1% presented with recurrence, and none developed foreign body sinus.

Conclusion:

The incidence of long-term complications of three stitch hernioplasty are comparable to that of the other standard, tension-free open hernia repair as well as other laparoscopic procedures. Moreover, the three stitch hernioplasty method is a simple method, easy for the beginners to adopt, has less foreign body reaction, less time consuming, causes less tissue trauma, and lesser chance for vascular injury.

Prophylactic mesh placement in high-risk patients undergoing elective laparotomy: a systematic review

BACKGROUND

Incisional hernia is a significant complication in patients undergoing elective laparotomy. Its incidence is increased in patients with risk factors, such as obesity and chronic respiratory disease. The purpose of this pooled analysis was to evaluate the use of prophylactic mesh placement following laparotomy in high-risk patients.

METHODS

A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane database was conducted. Outcome measures were incidence of postoperative incisional hernia, seroma, and wound infection rates.

RESULTS

Five randomized, controlled trials (RCTs) and four comparative studies that met the inclusion criteria were identified. In total, 464 patients who underwent laparotomy closure with mesh placement and 755 patients who underwent conventional laparotomy closure were included. A reduced incidence of incisional hernia was observed when laparotomy was combined with prophylactic mesh placement in pooled analysis of RCTs (pooled odds ratio = 0.32; 95 % confidence interval = 0.12-0.83; P = 0.02) and comparative studies (pooled odds ratio = 0.11; 95 % confidence interval = 0.04-0.33; P < 0.001) respectively. No significant differences were observed in the incidence of seroma or wound infection following prophylactic mesh placement.

CONCLUSIONS

The results of this pooled analysis suggest a benefit to prophylactic mesh placement during laparotomy closure in high-risk patients with a significantly reduced incidence of incisional hernia without any significant differences in seroma formation and wound infection rates. Further studies must evaluate the incidence of mesh-specific complications, including foreign body sensation and chronic pain, before strong recommendations can be made.

Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations: single-centre experience including clinical examination and interview

AIM

The aim of the study was to describe long-term subjective and objective results of pelvic floor reconstruction using an absorbable biological mesh after extralevator abdominoperineal excision (ELAPE) for low rectal cancer.

METHOD

Records of 53 patients who had an ELAPE with reconstruction of the pelvic floor with a Permacol® mesh between August 2007 and August 2011 were reviewed. Thirty-one of the patients were called for interview and clinical examination.

RESULTS

Three (6%) patients developed perineal hernia, 11 had fistulae (nine of which were treated successfully), four patients had a perineal abscess and four patients had superficial wound infections. Removal of the mesh was necessary in one case, while another patient needed implantation of a new mesh. In 13 of the 31 interviewed patients, long-term pain was present, but resolved after a median of 8 months (3-56). No major sitting or movement disabilities were encountered. Three-year survival was 82%, and no local recurrences were found.

CONCLUSION

Pelvic floor reconstruction with a biological mesh is a feasible solution when performing ELAPE for low rectal cancer, although long-term pain is a frequent complication.

Impact of pericardium bovine patch (Tutomesh(®)) on incisional hernia treatment in contaminated or potentially contaminated fields: retrospective comparative study

PURPOSE

This retrospective comparative study analyzes the outcome of patients affected by incisional hernia in potentially contaminated or contaminated field, treated by three operative techniques.

METHODS

152 patients (62 M:90 F; mean age 65 ± 14 years) underwent incisional hernia repair (January 2002-January 2012) in complicated settings. Criteria of inclusion in the study were represented by the following causes of admission: mesh rejection/infection, obstruction without gangrene but with possible peritoneal bacterial translocation, obstruction with gangrene, enterocutaneous fistula or simultaneous presence of ileo- or colostomy. The patients were divided into three groups: A (n = 76), treated with primary closure technique; B and C (n = 38 each), with reinforcement by synthetic or pericardium bovine mesh (Tutomesh(®)), respectively. The prosthetic groups were divided into Onlay and Sublay subgroups.

RESULTS

Significant decreases in C vs A were observed for wound infection (3 vs 37%) and recurrence (0 vs 14%), and in C vs B for wound infection (3 vs 53%), seroma (0 vs 34%) and recurrence (0 vs 16%). Patients with concomitant bowel resection (BR) (43%) showed (all P < 0.05) an increase of overall morbidity (55 vs 33%) and wound infection rate (42 vs 24%) compared to cases without BR. Morbidity presented no significant differences in C-Onlay or Sublay subgroups. B-Sublay subgroup has (all P < 0.05) lower overall morbidity (20 vs 75%), wound infection (10 vs 68%) and seroma (0 vs 46%) than B-Onlay.

CONCLUSIONS

The pericardium bovine patch seems to be safe and effective to successfully repair ventral hernia in potentially contaminated operative fields, especially in association with bowel resection.

Risk factors for chronic pain after open ventral hernia repair by underlay mesh placement

BACKGROUND

Incisional hernia is a frequent complication following abdominal surgery. Repairs that include the use of mesh have been associated with decreased recurrence. The aim of the present study was to determine the outcomes and risk factors for chronic pain after ventral hernia repair with underlay placement of a composite polypropylene mesh.

METHODS

A retrospective study was conducted from September 2005 to June 2008. The study included consecutive patients who underwent elective incisional hernia repair with underlay composite mesh placement. Postoperative course, recurrence, pain, and patient satisfaction were assessed by an independent observer. Chronic pain was defined as significant pain persisting after 3 months as assessed using a 10-point numeric scale (≥ 3: chronic pain, ≥ 7: severe pain).

RESULTS

After a mean follow-up period of 24.6 months, 109 of 121 patients operated on during the period were evaluated. No patients experienced small bowel obstructions, enterocutaneous fistulas, or mesh infections leading to the need for mesh removal. The recurrence rate was 6.1 % at the repair site and 10.5% at another site. Thirty-one patients (28%) had chronic pain and seven patients (6.6%) had severe pain. Affective and nociceptive components were the majority of complaints. Chronic cough was the only variable independently associated with chronic pain in univariate and multivariate analyses (OR = 4.8; p = 0.007).

CONCLUSIONS

Intraperitoneal composite mesh placement after ventral hernia repair is safe with regard to intra-abdominal potential complications. Chronic pain is not uncommon, with chronic cough identified as the major independent predictor.

A comparative analysis on various techniques of incisional hernia repair-experience from a tertiary care teaching hospital in South India

This prospective study was conducted at a tertiary care teaching hospital in South India over a period of 7 years and included 90 patients with incisional hernia (n = 90; 76 females and 14 males), operated over 2 years (January 2004 to December 2005), and followed-up for 5 years postoperatively (2005-2009). As per the surgical unit preference, patients underwent different methods of hernia repair-onlay mesh repair (n = 45, 50 %), underlay mesh repair (n = 18, 20 %), and anatomical repair (i.e., without mesh) (n = 27, 30 %). Parameters studied included seroma formation, wound infection, postoperative pain, and hernia recurrence. Although the first two parameters were statistically not significant, postoperative pain was found to be more in patients who underwent an underlay repair. A significant difference in the hernia recurrence rate was observed between mesh repair and anatomical repair groups. Hence, we conclude that all incisional hernias should be repaired with a mesh (meshplasty).

[Abdominal wall closure by incisional hernia and herniation after laparostoma]

As hernias and abdominal wall defects have a variety of etiologies each with its own complications and comorbidities in various constellations, efficient treatment requires patient-oriented management. There is no recommended standard treatment and the very different clinical pictures demand an individualized interdisciplinary approach. Particularly in the case of complicated hernias, the planning of the operation should focus on the problems posed by the individual patient. Treatment mainly depends on the etiology of the hernia, immediate or long-term complications and the efficiency of individual repair techniques. Abdominal wall repair for recurrent herniation requires direct closure of the fascia generally using the sublay technique with a lightweight mesh. It is still unclear whether persistent inflammation, mesh dislocation, fistula formation or other long-term complications are due to certain materials or to the surgical technique. With mesh infections it has been shown to be advantageous to remove a polytetrafluoroethylene (PTFE) mesh, while the combination of systemic and local treatment appears to suffice for a polypropylene or polyester mesh. Heavier meshes in the sublay position or plastic reconstruction with autologous tissue are indicated as substitutes for the abdominal wall for giant hernias, repeated recurrences and large abdominal wall defects. A laparostoma is increasingly more often created to treat septic intra-abdominal processes but is very often responsible for a complicated hernia. If primary repair of the abdominal wall is not an option, resorbable material or split skin is used for coverage under the auspices of a planned hernia repair.

Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.

Pelvic floor reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection

PURPOSE

Patients who undergo cylindrical abdominoperineal resection can have significant complications, especially those who require pelvic reconstruction using myocutaneous flaps. Reconstruction using a biomaterial may be a novel alternative. The purpose of this study is to report the initial results of pelvic reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection.

METHODS

Between January 2008 and February 2009, pelvic floor reconstruction was performed in 12 consecutive patients who underwent cylindrical abdominoperineal resection for advanced ultralow rectal cancer.

RESULTS

Two weeks after the operation, primary complete healing of the perineal wound was seen in 11 patients. At a median follow-up of 8 months, there was no perineal wound breakdown, bulge, or herniation. One patient had an asymptomatic seroma, one patient had a perineal wound infection, and 4 patients had perineal pain that resolved.

CONCLUSIONS

Human acellular dermal matrix provided a safe alternative for the reconstruction of large pelvic defect in the patients after cylindrical abdominoperineal resection.

Rectusbanding: a method for the repair of incisional hernias

BACKGROUND

We report on a new method of incisional hernia repair applicable to any size of hernia and the long-term results of this method. Musculus rectus abdominis is bandaged or partially bandaged in a loose way with a 2-cm-wide band of polypropylene (Prolene) on both sides at a distance of 2 cm, depending on the size of the hernial opening. The aims of this technique, which were defined in 1999 when we started using the method, were to find a simple method for surgeons, a safe mesh fixation and the prevention of a postoperative stiff abdomen. Another aim was to find a method for optimal patient care at reasonable costs.

METHODS

Two hundred and seventeen patients underwent an operation according to this method in our department from June 1999 until December 2007. The first 75 patients of this cohort were treated using a technique in which the musculus rectus abdominis was bandaged in a loose way. One hundred and forty-two patients (since October 2001) were treated using a technique in which the muscle was not entirely bandaged. Instead, the polypropylene bands, which had been placed in sublay position, were penetrating the lateral rim through incisions and were fastened there. We included 124 patients (October 2001 to December 2006) in our further examination with a follow-up of 17-79 months.

RESULTS

We found a recurrence rate of 6%, 80.1% of the patients had no trouble, 18.1% of the patients had very rarely any complaint, 0.9% of the patients had problems after exercise and 0.9% had permanent problems. All patients had excellent mobility of the abdomen.

CONCLUSION

This method was proven to give good results in the long run and can be easily learned by any surgeon. This method is a true alternative to all methods which have been published so far.

Human peritoneal membrane reduces the formation of intra-abdominal adhesions in ventral hernia repair: experimental study in a chronic hernia rat model

BACKGROUND

Adhesions leading to intestinal obstructions and fistulae are severe complications related to the intraperitoneal placement of synthetic meshes. This study evaluated the efficacy of human peritoneal membrane (HPM) in a chronic hernia repair rat model as an anti-adhesive solution for preventing the development of intra-abdominal adhesions.

MATERIALS AND METHODS

The mechanical properties of HPM and human fascia lata (HFL) were evaluated prior to in vivo implantation. Twenty rats underwent midline laparotomy, which led to the development of chronic hernias 28 d later. Then, animals underwent incisional hernia repair in an underlay fashion (n=5/mesh group) with compressed poly(tetra-fluoro-ethylene) (cPTFE), onto which HPM or HFL were affixed pre-repair, along with two additional controls. The extent and tenacity of intra-abdominal adhesions were determined through qualitative gross evaluations and quantitative tensiometry at 30 d post-repair. The host tissue response was evaluated histologically.

RESULTS

In hydrated state, the elastic properties of HPM were superior to HFL. Repairs with HPM had significantly less surface area covered by adhesions, with significantly lower tenacity compared with all other groups. Furthermore, intra-abdominal adhesions developed in the presence of HPM were associated with omentum only, and were distributed around the perimeter of the exposed cPTFE. HPM served as an active tissue remodeling template, replacing the traditional foreign body encapsulation with an anatomically and physiologically superior outcome.

CONCLUSIONS

HPM significantly reduces the extent and tenacity of intra-abdominal adhesion formation, and represents a bioprosthetic template that encourages structural and functional neo peritonealization.

Prophylactic prosthetic reinforcement of midline abdominal incisions in high-risk patients

BACKGROUND/AIM

Incisional hernia is one of the major elements of morbidity after abdominal surgery, with high incidence in vertical midline abdominal incisions. However, the risk of developing an incisional hernia can be increased due to the patient's related factors; therefore, more consideration has to be given to the choice of incision, wound closure and wound healing to protect against incisional hernia, especially in high-risk patients. In this study, we used prophylactic subfascial non-absorbable mesh reinforcement of midline closure in high-risk patients to detect whether fixing the wound with mesh is risky on a short-term basis and whether it is protective on a long-term basis.

PATIENTS AND METHODS

From October 2000 to December 2002, 40 high-risk patients liable to develop postoperative incisional hernia underwent elective abdominal operations through midline abdominal incisions at the Department of Surgery, Gastroenterology and Laparoscopic Unit, Tanta University Hospital, Egypt. They were randomly divided into two groups; group A: patients for whom the midline abdominal incisions were closed by conventional method and reinforced by subfascial polypropylene mesh (20 patients); and group B: patients for whom the midline abdominal incisions were closed by conventional method only (20 patients) with a follow up period of more than 20 months.

RESULTS

There was no significant difference (P = 0.075) in both groups regarding the age, sex and the average risk factor. Twenty-three patients (57.5%) presented with more than one risk factor (11 in group A and 12 in group B). The upper midline abdominal incisions were reported in 33 patients (19 upper and 14 extended upper). There was no significant difference between the overall local and systemic complications in both groups (P = 0.4082). However, the subcutaneous seroma and chronic wound pain were greater in patients with prophylactic mesh than those without mesh. One group A patients (5%) and three group B patients (15%) developed postoperative incisional hernia during the follow up period.

CONCLUSION

Prophylactic subfascial non-absorbable mesh reinforcement of midline closure in high-risk patients can be used safely and effectively to provide extrinsic strength of the wound without relying too much on the defective development of its own intrinsic strength and to prevent subsequent incisional hernia. There was no risk in the use of the mesh regarding local and systemic complication. However, the final statement should await the outcomes of the long-term follow up of the studied cases.

Open randomized clinical trial of laparoscopic versus open incisional hernia repair

BACKGROUND

Incisional hernia is a common complication following abdominal surgery. Although the use of prosthetics has decreased recurrence rates, the standard open approach is still unsatisfactory. Laparoscopic techniques are an attempt to provide similar outcomes with the advantages of minimally invasive surgery.

METHODS

Open randomized controlled clinical trial with follow-up at 1, 2, 3, 7, and 15 days, and 1, 3, and 12 months from hernia repair. The study was carried out in the surgery departments of three general hospitals of the Valencia Health Agency.

OBJECTIVES

To compare laparoscopic with anterior open repair using health-related quality of life outcomes as main endpoints.

RESULTS

Eighty-four patients with incisional hernia were randomly allocated to an open group (OG) (n = 39) or to a laparoscopic group (LG) (n = 45). Seventy-four patients completed 1-year follow up. Mean length of stay and time to oral intake were similar between groups. Operative time was 32 min longer in the LG (p < 0.001). Conversion rate was 11%. The local complication rate was superior in the LG (33.3% versus 5.2%) (p < 0.001). Recurrence rate at 1 year (7.9% versus 9.7%) was similar in the two groups. There were no significant differences in the pain scores or the EQ5D tariffs between the two groups during follow-up.

CONCLUSIONS

Laparoscopic incisional hernia repair does not seem to be a better procedure than the open anterior technique in terms of operative time, hospitalization, complications, pain or quality of life.

Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study

BACKGROUND

Incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair to various mesh repairs and laparoscopic repair. Laparoscopic mesh repair is a promising alternative, and in the absence of consensus, needs prospective randomized controlled trials.

METHODS

Between April 2003 and April 2005, 66 patients with incisional, primary ventral and recurrent hernias were randomized to receive either open retro-rectus mesh repair or laparoscopic mesh repair. These patients were followed up at 1-, 3-, and 6-month intervals thereafter for a mean of 12.17 months (open repair group) and 13.73 months (laparoscopic repair group).

RESULTS

Lower abdominal hernias after gynecologic operations constituted the majority of the hernias (approximately 50%) in both groups. There was no significant injury to viscera or vessel in either group and no conversions. The defect size was 42.12 cm in the open (group 1) and 65.66 cm2 in the laparoscopic group (group 2), and the prosthesis sizes were, respectively, 152.67 cm2 and 203.83 cm2. The hospital stay was 3.43 days in open group and 1.47 days in laparoscopic group (p = 0.007). There was no significant difference in the pain scores between the two groups. More wound-related infectious complications occurred in the open group (33%) than in the laparoscopic group (6%) (p = 0.013). There was one recurrence in the open repair group (3%) and two recurrences in laparoscopic group (6%) (p = 0.55).

CONCLUSIONS

Laparoscopic repair of incisional and ventral hernias is superior to open mesh repair in terms of significantly less blood loss, fewer complications, shorter hospital stay, and excellent cosmetic outcome.

Experience with Porcine Acellular Dermal Collagen Implant in One-stage Tension-free Reconstruction of Acute and Chronic Abdominal Wall Defects

BACKGROUND

Elective or emergency reconstruction of abdominal wall defects (AWD) is often difficult. Various techniques have been proposed for reconstructing AWD, including the use of synthetic implants. Porcine acellular dermal collagen (Permacol(TM)) is a biologic implant (PADCI) derived from porcine dermis. We report our experience with the use of PADCI in the management of large AWD in both emergency and elective surgery.

METHODS

Twenty consecutive patients with chronic AWD (CAWD) arising from large incisional hernia or acute AWD (AAWD) arising from visceral edema or tumor resection were studied prospectively. After musculofascial mobilization, the AWD was closed using sheets (10 x 15 cm) of PADCI as an "underlay" interposition graft. Patients were followed up to a median of 18 months postoperatively.

RESULTS

All 20 defects were closed without tension using PADCI. Eight and 12 patients had reconstruction for large AAWD and CAWD, respectively. The mean size of the defects was 180 cm(2) (range = 96-850 cm(2)). The median number of PADCI used to repair the defects was one sheet (range = 1-7). Twelve patients (60%) had an uneventful recovery and were discharged within seven days. One patient (5%) died from multiple-organ failure. Seven patients (35%) developed a complication (two seromas, two minor wound infections, one wound hematoma, one skin edge necrosis, one superficial wound dehiscence, and wound sinus). Overall there were three recurrences (15%).

CONCLUSION

PADCI has the potential for reconstruction of large acute and chronic abdominal wall defects. Medium-term recurrence rate is comparable to synthetic mesh repairs.

Are mesh anchoring sutures necessary in ventral hernioplasty? Multicenter study

BACKGROUND

Avoiding mesh fixation to the surrounding tissue in ventral hernioplasty would simplify the operation, decrease the time of the procedure, and decrease the risk of suture-related complications.

METHODS

Four hospitals included 111 patients according to the common protocol for prospective clinical evaluation of sutureless ventral hernioplasty. Surgical technique involves placement of the polypropylene mesh with flat-shape memory in either the retromuscular or preperitoneal space without suture anchoring.

RESULTS

Local complication rate was low (12.6%, 14 patients), postoperative pain measured according to the visual analogue scale was minimal (mean 4, range 1-8). Three recurrences (3%) were recorded. Mild scar discomfort, which did not require treatment nor limit physical activity, was recorded in 28 (25%), 18 (17%), and 11 (14%) patients at 6-month, 1- and 2-year follow-up, respectively.

CONCLUSIONS

Results of the study suggest that the sutureless sublay technique is safe and effective in the treatment of ventral abdominal hernia, especially in small and medium defects.

Open Mesh Repair of Incisional Hernia Using a Sublay Technique: Long-Term Follow-up

BACKGROUND

Reported results of incisional hernia repair are poor with high recurrence rates unless prosthetic mesh is used. Mesh gives improved results, but certain techniques are associated with a high incidence of infections, fistulas, and seromas. This study reports the results of a consecutive series of incisional hernias repaired using an open sublay technique with retromuscular mesh placement. The primary endpoint was hernia recurrence. Secondary endpoints were complications and long-term discomfort.

METHODS

A total of 125 patients were operated on between 1991 and 2001. In 2002 they were sent a questionnaire and asked to return for examination if they thought their hernia had recurred or if they had pain. A second questionnaire was sent in 2005, and all patients were asked to return for examination.

RESULTS

There were no postoperative deaths and no major systemic complications. There were no early (within 30 days) wound infections; the mesh subsequently became infected in two patients and had to be removed. Seromas developed in 12 patients. In 2002, a total of 106 questionnaires were returned; 3 patients had died of unrelated causes, and 16 were untraceable despite repeated attempts. There were five (4%) recurrences. Altogether, 6 patients had abdominal wall discomfort, and 49 patients spontaneously wrote that they were pleased or very pleased with the long-term result. At a second follow-up a mean of 8 years after operation (95 months; range 46-168 months) patients were assessed by an independent observer, and there were no further recurrences.

CONCLUSIONS

Open repair of incisional hernias with mesh in the subfascial plane is highly effective with acceptable complication rates. Surgeon experience and a team approach are important factors in obtaining good results. Trials comparing open with laparoscopic repair are needed.

Operative treatment of ventral hernia using prosthetic materials

OBJECTIVE

The objective of this study was to summarize the clinical experiences in repairing abdominal incisional hernia with prosthetic materials.

METHODS

Eighty-three patients with ventral hernia were analyzed retrospectively.

RESULTS

Two patients developed pulmonary infection, one developed adhesive ileus, and five developed wound infection. All wounds healed completely during follow-up. Seventy-three (88%) patients were free of pain, and ten patients (12%) felt pain in the operated area within the last month; only one patient required pain-relieving drugs. Twenty-nine patients (35%) felt discomfort, such as stiffness. Four cases experienced postoperative recurrence.

CONCLUSIONS

Incisional herniorrhaphy with prosthetic materials is safe and effective but has a high discomfort rate. Open giant incisional hernia or recurrent incisional hernia should be performed by trained surgeons. Placing mesh in a suitable position and using a patch with minimal reaction and enough tensile strength may improve the prognosis. Further studies are necessary utilizing light polypropylene mesh.

Tensile Strength Comparison of Small Intestinal Submucosa Body Wall Repair

BACKGROUND

Porcine small intestinal submucosa (SIS) has been studied for body wall repair. However, the best method to implant the biological material has not been investigated. The objective of this study was to compare tensile strengths achieved after healing when SIS was placed using three implant techniques (onlay, inlay, underlay) in a porcine model of abdominal wall defect.

MATERIALS AND METHODS

Twenty female domestic pigs had three abdominal midline sites assigned to one of five test groups: SIS implantation using inlay, onlay, or underlay technique; sham surgery (sutured midline incision) or normal body-wall control. Full-thickness muscle/fascia midline abdominal defects (6 x 4 cm) were surgically created and then repaired using eight-layer SIS. Healing was evaluated at 1 and 4 post-operative months by tensile strength testing and histopathology.

RESULTS

Hernias were not observed. Tensile strengths were not statistically different between the five test groups (P = 0.39) or between months 1 and 4 (P = 0.35). The caudal site was stronger than the cranial or middle sites in the 1 month group (P < 0.0001). Histologically, healing appeared to progress over time as the repair site showed remodeling towards an interlacing fibrous connective tissue pattern.

CONCLUSIONS

No significant differences in tensile strength were found between implant techniques and were not statistically different from sham surgery and normal control tissue. This study suggested that SIS healing/remodeling provides sufficient tensile strength for the repair of ventral (anterior) abdominal wall defects when implanted using any of three common techniques.

Laparoscopic incisional hernia repair: a review of the literature

Incisional hernia is a common long-term complication of abdominal surgery. Historically the open repair with or without mesh was the mainstay of treatment. However, many recently published laparoscopic repair studies have challenged surgeons to re-evaluate which technique provides the best short and long-term outcomes. A Medline search of all English-language literature was performed using the keywords 'incisional', 'ventral', 'hernia', 'laparoscopic', and 'open'. Further references were obtained by cross-referencing the bibliography in each paper. Current evidence suggests that the laparoscopic incisional hernia repair is the optimal surgical treatment. A laparoscopic repair appears to shorten hospital stay, decrease perioperative complication rates, and decrease recurrence rates. However, there is no randomized trial utilizing a standardized complication grading system making it difficult to draw a definitive conclusion as to which repair is best.

Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair

BACKGROUND

Polymer mesh has been used to repair incisional hernias with lower recurrence rates than suture repair. A new generation of mesh has been developed with reduced polypropylene mass and increased pore size. The aim of this study was to compare standard mesh with new lightweight mesh in patients undergoing incisional hernia repair.

METHODS

Patients were randomized to receive lightweight composite mesh, or standard polyester or polypropylene mesh. Outcomes were evaluated at 21 days, 4, 12 and 24 months from patient responses to the Short Form 36 (SF-36) and daily activity questionnaires. Complications and recurrence rates were recorded.

RESULTS

A total of 165 patients were included in an intention-to-treat analysis (83 lightweight mesh, 82 standard mesh). Postoperative complication rates were similar. The overall hernia recurrence rate was 17 per cent with the lightweight mesh versus 7 per cent with the standard mesh (P = 0.052). There were no differences in SF-36 physical function scores or daily activities between 21 days and 24 months after surgery.

CONCLUSION

The use of the lightweight composite mesh for incisional hernia repair had similar outcomes to polypropylene or polyester mesh with the exception of a non-significant trend towards increased hernia recurrence. The latter may be related to technical factors with regard to the specific placement and fixation requirements of lightweight composite mesh.

Incisional hernia—comparison of mesh repair with Cardiff repair: an university hospital experience

BACKGROUND

Incisional hernia is a frequent complication of abdominal surgery. Various types of repair are recommended for incisional hernia. Suture and mesh repair are compared in the present study.

METHOD

One hundred seventy one patients with incisional hernia underwent Cardiff repair (far and near sutures with reinforcement sutures) which was used as an open suture repair while onlay polypropylene mesh was used in the mesh repair technique.

RESULT

Cardiff repair was performed in 116 patients with no mortality with recurrence in two patients with mean follow up of 7.1 years. Both these patients with recurrence had a defect measuring more than 10 cm in width. Mesh repair was carried out in 55 patients with no recurrence in mean follow up of 37 months. Seroma formation was noted in 7 (12.72%) with mesh repair as compared to 4 (3.44%) patients with Cardiff repair.

CONCLUSION

We recommend Cardiff repair for primary and small to medium size incisional hernias. Onlay polypropylene mesh is ideal for tension-free hernia repair, recurrent incisional hernia and hernia defects wider than 10 cm.

Narbenhernien

With a long-term incidence of 10-20%, incisional hernias remain one of the most common surgical complications. Beside technical causes, wound-healing problems are increasingly being discussed. Conventional suture repair shows disappointing results and should be used only in selected cases. By the implantation of mesh prostheses, notable improvement could be achieved, with recurrence rates of <10%. Its main principle is retromuscular mesh reinforcement of the entire scar. Particularly in the neighbourhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris.

Operative treatment of massive ventral hernia using polypropylene mesh: A challenge for surgeon and anesthesiologist

OBJECTS

Surgical repair of very large ventral hernias has become feasible after the introduction of synthetic meshes and developments in intensive-care treatment. In addition to the operative challenges, postoperative disorders in the cardiovascular system, tissue oxygenation, increased intra-abdominal pressure, and pulmonary embolism expose the patient to severe risks.

METHODS

From 1997-2002 we operated on ten patients with giant ventral incisional or umbilical hernia (mean defect size 240 cm(2)) by using retromuscular polypropylene mesh. All patients were morbidly obese [mean Body Mass Index (BMI) 39+/-7.2 kg/m(2)]. Four of the operations were emergencies because of an acute intestinal occlusion, bowel gangrene, and skin complications. The patients were reinvestigated after the mean follow-up of 2.5 years to find out the frequency of recurrence and degree of disability.

RESULTS AND CONCLUSION

There was no intraoperative mortality, but one patient died at home after 5 weeks because of myocardial infarct and prolonged wound infection. She had mild stable coronary heart disease preoperatively. Although minor wound complications were observed in three patients, there was no need to remove the meshes. One small recurrent hernia was observed in the follow-up, but it was too small to be repaired. The quality of life after surgery was good for all patients, and they were satisfied with the operation. Retromuscular mesh hernioplasty associated with careful patient monitoring in intensive care is safe and feasible in the selected patients with massive ventral hernia.

A review of incisional hernia repairs: preoperative weight loss and selective use of the mesh repair

At the Shouldice Clinic pre-operative weight loss is used prior to incisional hernia repairs. Mesh repair is selectively used, based on specific hernia characteristics. A series of 236 patients were reviewed and followed up for 36 months. Data were available on 188 patients (80%). There were 15 recurrences (8%). The number of obese patients was reduced from 67 (35.6%) to 25 (13.3%) through the weight loss program. The hernia diameter, gastrointestinal complications, and surgical site infection were significantly related to recurrence but not the type of repair, obesity, location, or previous recurrences. The risk factors of incisional hernias include size, intestinal complications and infections. A selective use has a comparable result to the exclusive use of mesh repair. Weight reduction has yet to be shown to affect the rate of recurrence, and further prospective studies are required.

Long-term pain and recurrence after repair of ventral incisional hernias by open mesh: clinical and MRI study

BACKGROUND AND AIMS

Polypropylene mesh repair of large incisional ventral hernias has become increasingly popular. Long-term effects of the mesh on pain and abdominal muscles are not known.

PATIENTS/METHODS

Retromuscular pre-peritoneal polypropylene mesh was placed by open technique in 84 consecutive patients with large ventral hernias (mean defect size 130 cm(2)). We re-examined the patients after a mean follow-up time of 3 years to find out the frequency of recurrence and chronic pain. We measured the thickness of abdominal muscles of eight patients preoperatively, and postoperatively after 1 year, using magnetic resonance imaging (MRI).

RESULTS

Recurrent hernias had appeared in four patients (5%) at follow-up. Nine patients (13%) needed occasional pain-relieving drugs, but only three (4%) suffered persistent, severe, pain from the mesh. Some limitation during leisure-time physical activities was found in 10% of patients. Only ten patients (12%) were re-operated on because of wound complications or recurrence. MRI study indicated that abdominal muscles were postoperatively well preserved. Although wound infections (6%) and seroma (9%) were frequent complications, there was no need for meshes to be removed in the follow-up.

CONCLUSION

Open ventral herniorrhaphy with mesh is safe, effective and inexpensive. Small, recurrent hernias were infrequent and easy to re-operated on. Severe pain from the mesh was not common. Postoperative MRI study indicated no obvious damage of abdominal muscles after mesh placement.

Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia -- 25 women and 28 men, mean age 60.4 (range 28-94) -- were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.

Surgical treatment of incisional hernia

BACKGROUND

Incisional hernia is a common complication of abdominal surgery and an important source of morbidity. It may be repaired using open suture, open mesh or laparoscopic mesh techniques. This review examines the results of these methods of repair.

METHODS

A Medline literature search was performed to identify articles relating to 'incisional hernia', 'ventral hernia' and 'wound failure'. Relevant papers from the reference lists of these articles were also sought.

RESULTS

The recurrence rate after open suture repair may be as high as 31-49 per cent; for open mesh repair it is between 0 and 10 per cent. Comparative studies show that recurrence is significantly more frequent after open suture repair than after open mesh repair; complication rates are similar for both procedures. Recurrence rates after laparoscopic mesh repair vary from 0 to 9 per cent. Comparative studies show that laparoscopic mesh repair is at least as safe and effective as open mesh repair.

CONCLUSION

Open suture repair for incisional hernia carries an unacceptably high recurrence rate. The results of open mesh and laparoscopic mesh techniques are encouraging. There is scope for a large multicentre randomized clinical trial to compare laparoscopic and open mesh repair.