INCISIONAL HERNIA REPAIR

Incidence: Each year approximately 2 million laparotomies are performed, with an incisional hernia rate of 2-11% Approximately 100,000 incisional ventral hernia repairs performed annually in U.S. Recurrence rates after incisional hernia repair are between 10% and 50% More than 50% of incisional hernias present within first 2 years after primary operation Presentation: First sign is usually an asymptomatic bulge noticed by the patient Over time, incisional hernias enlarge and become painful with movement, straining, or coughing Uncommon symptoms are vomiting, obstipation, or severe pain; but when present can be associated with incarceration or strangulation resulting in emergency OR Risk factors: Wound infection, abdominal distention, pulmonary complications, obesity, emergency procedures, early re-operation, underlying disease process, type of closure, suture material used in closure, and choice of original incision Incidence of incisional hernia after bariatric procedures is approx. 15-20% Wound infection is most significant independent factor for incisional ventral hernia. In patients with post-operative wound infection, there is a 23% risk of hernia Studies suggest that transverse incisions have lower rate of incisional hernias than midline incisions No significant difference between continuous vs. interrupted suture closure Types of Repair: primary, primary with relaxing incisions, primary with onlay mesh reinforcement, onlay mesh only, inlay mesh placement, retrorectus mesh placement, and intraperitoneal mesh placement Primary repair o Usually for facial defects less than 5 cm in diameter o Recurrence rates of approximately 50% have been reported o There is tension present in this repair. May use relaxing incisions to reduce tension (eg. Keel procedure, separation-of-parts technique) Mesh Products o absorbable meshes only used in cases where mesh infection is a significant risk and cannot perform primary closure o polyester mesh associated with higher rates of entero-cutaneous fistula formation and mesh infection o polypropylene has greatest tissue ingrowth of all meshes available o PTFE has fewest bowel complications due to its nonadhesiveness to bowel

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Material Polypropylene

Polytetrafluorethylene (PTFE)

Polyester Polyamide Polyglactin 910 Polyglycolic acid

Product name Marlex (monofilament) Prolene (double filament) Surgipro (multifilament) Atrium (multifilament) Vypro (multifilament) Teflon (multifilament) Gore-Tex (soft tissue-patch) Dualmesh Parietex Mersilene (multifilament) Dacron Nylon Vicryl (resorbable) Dexon (resorbable)

Prosthetic mesh repairs Primary closure with mesh reinforcement: an onlay, usually of polypropylene mesh, is sutured to anterior rectus sheath after fascial defect has been closed primarily. Advantage is that this repair keeps mesh separated from abdominal contents; disadvantage is wound repair under tension, and mesh infection when surgical wound is infected Inlay mesh repair: hernia sac is excised and fascial margin is identified around the hernia defect. Either polypropylene or ePTFE is sutured circumferentially to fascial edge. Polypropylene would be used when omentum can be placed between intestine and mesh; ePTFE should be used when there is no omentum available Retrorectus mesh repair: aka Rives-Stoppa technique. This technique utilizes the hernia sac to separate the mesh from the intra-abdominal contents. Superior to the umbilicus, dissection is performed above the posterior rectus fascia and under the rectus muscle. Below the umbilicus, dissection occurs in the preperitoneal space due to the lack of a posterior rectus sheath. A large piece of mesh is placed in the newly formed space, and fixated to the muscle layer above. This repair has decreased recurrences and complications from previous techniques. o In the study Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients there were no hernia recurrences, GI complications, fistulas, or deaths in 57 patients who had a Rives-Stoppa incisional hernia repair using either polypropylene or ePTFE. Of the 57 patients, 7(12.3%) had post-op seromas and 2(3.5%) had wound infections that required removal of prosthesis. In this study, both polypropylene and ePTFE meshes were used with no statistical difference among them in terms of recurrence, fistulization, or GI complications. However, there may be an advantage with ePTFE if there is breakdown of the posterior sheath and the mesh comes into contact with bowel. Intraperitoneal underlay mesh repair: this method allows for largest underlay of mesh on the fascia or abdominal wall, which reduces recurrence because a larger amount of tissue ingrowth can occur. Technique can be performed either open or laparoscopically.

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If there is too much tension to close an abdominal wall defect primarily, and mesh is contraindicated, there is an algorithm of options that can be considered: 1)Primary closure: avoid tension 2)Mesh:10% hernia recurrence,7% infection 3)Skin grafts:over viscera, mesh, omentum 4)Fascial release 5)Components seperation 6)Tissue expansion 7)Pedicle muscle and myocutaneous flaps: TFL, rectus femoris, vastus lateralis, gracilis 8)Free flaps

References: 1)Millikan, KW. Incisional hernia repair. Surgical clinics of North America; 1993 Oct; 83(5) 2)Bauer JJ, Harris MT, Gorfine SR, Kreel I. Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients. Hernia; 2002 Sept; 6(3): 120-3 3)Luijendijk, RW, et al. A comparison of suture repair with mesh repair for incisional hernias. The New England Journal of Medicine. 2000 Aug; 343(6) 4)Holzheimer, RG; Mannick JA. Book: Surgical Treatment: evidence based and problem oriented. 2001 copyright W. Zuckschwerdt Verlag GmbH Michael Wolfeld M.D. August 23, 2004

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Illustrations are from Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients by Bauer, Harris, Gorfine and Kreel

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