Incisional Hernia Repair

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INCISIONAL HERNIA REPAIR

Incidence:

Each year approximately 2 million laparotomies are performed, with an incisional herniarate 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 beassociated 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, suturematerial 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 thanmidline incisions

No significant difference between continuous vs. interrupted suture closureTypes 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 repairo Usually for facial defects less than 5 cm in diametero Recurrence rates of approximately 50% have been reportedo There is tension present in this repair. May use relaxing incisions to reduce

tension (eg. Keel procedure, separation-of-parts technique)

Mesh Productso 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 formationand mesh infection

o polypropylene has greatest tissue ingrowth of all meshes availableo PTFE has fewest bowel complications due to its nonadhesiveness to bowel


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Material Product name

Polypropylene Marlex (monofilament)

Prolene (double filament)Surgipro (multifilament)

Atrium (multifilament)Vypro (multifilament)Polytetrafluorethylene (PTFE) Teflon (multifilament)

Gore-Tex (soft tissue-patch)

DualmeshParietex

Polyester Mersilene (multifilament)

DacronPolyamide Nylon

Polyglactin 910 Vicryl (resorbable)

Polyglycolic acid Dexon (resorbable)

Prosthetic mesh repairs

Primary closure with mesh reinforcement: an onlay, usually of polypropylene mesh, issutured 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 herniadefect. 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 herniasac 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 aposterior 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-opseromas and 2(3.5%) had wound infections that required removal of prosthesis.

In this study, both polypropylene and ePTFE meshes were used with no statisticaldifference 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 onthe 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 iscontraindicated, there is an algorithm of options that can be considered:

1)Primary closure: avoid tension 5)Components seperation

2)Mesh:10% hernia recurrence,7% infection 6)Tissue expansion3)Skin grafts:over viscera, mesh, omentum 7)Pedicle muscle and myocutaneous flaps: TFL,

rectus femoris, vastus lateralis, gracilis

4)Fascial release 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 problemoriented. 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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Incisional Hernia Repair