Outcome of tension free repair of incisional hernia

Outcome of tension free repair of incisional hernia

Mohamed H. El-Ghor, MD; M.A.Marzouk, MD; Ehab H. Abd EI-Wahab, MD;

Mohamed Rady, MD

Departmrnt of General  Surgery, Ain Shams University, Cairo, Egypt.

Background: The surgical treatment ofincisional hernia has changed rapidly during the last decade with the increasing use of mesh technique and the introduction oflaparoscopy. However, many questions  concerning mesh type, mesh positioning, fixation method and operation type still remain unanswered.

Methods: The study includes 100 cases of anterior abdominal wall hernias, including incisional hernia (cicatricial  or paralytic types). The idea of the tension free repair of anterior abdominal wall hernia depends  on repair of the defect by double layer onlay polypropylene mesh the deeper mesh is fixed to the free edge of the defect by polypropylene (No.1). The mean operative time was 2 hours (ranging  between 1.5- 4 hours). Follow up of the patients was performed every 3 month with maximum follow up of two years and a minimum of six months.

Results:  The early postoperative course was uneventful in 96 patients (96%). Four patients presented with  wound infection,  two patients  presented  with superficial infection,  the other two patients presented with deep infection and exposed mesh. The follow up revealed 8 cases of recurrent hernia (8%), two ofthese cases were associated  with obesity, and one case was associated with bronchial asthma.

Conclusion: In our  study  we modified  the onlay  technique  for incisional  hernia  repair by using double layer onlay polypropylene  mesh the deeper mesh is fixed to the free edge of the external oblique muscle, this modification insured a tension free repair of the hernia, the technique is universal and can be applied in both scar and paralytic insicional hernia.

Key words: Incisional hernia, tension free repair, onlay repair.

Introduction:

The field of hernia surgery has changed markedly   within  the  past   decade.   Today, every patient and every surgeon has the choice between various techniques and devices to repair incisional hernias. Lots of publications confirm that most of them can be applied with success. The overall low recurrence rates published make it difficult to decide, which one is the best.l

Thousands of laparotomy incisions are performed   each   year,  the  failure   rate  for closure of these abdominal wounds is between

10-15%,  thus  creating   the  overwhelming problem of incisional hernia.2

Incisional   hernia   is   defined   as   "Any abdominal wall gap with or without bulge in the  area  of a postoperative  scar  perceptible or palpable by clinical examination or imaging".3

The risk of acquiring incisional hernia is heightened by several risk factors including obesity, diabetes, emergency surgery, postoperative   wound   dehiscence,   smoking and postoperative wound infection.4

Inscisional hernia inflicts at least 400,000 to 500,000 patients in the United States alone per year. The burden of incisional hernias varies widely but primarily comprises pain at the site of the hernia, limitations of activity, intestinal  obstruction,  skin  ulceration,  and even death due to compromise ofthe intestinal blood supply have been reported.S

When morbidity is added to the huge numbers and the tremendous costs associated with incisional hernia repair, it becomes clear that the efficacy  of incisional hernia  repair  is of major  importance.6

Prevention of incisional hernia  presents  a difficult challenge owing to the multifactorial nature  of its incidence; weight  reduction and treatment of predisposing factors  and pre­ existing illnesses  is advised before abdominal surgery.7

Several    classifications   of   hernia   were suggested,     based     on     localization,    stze,abdominal wall hernias,  including incisional hernia (cicatricial or paralytic types). The recurrent  cases are included  in the study, the patients  were operated  on between  2010  and 2012.

Selection Criteria: Patients with incisional hernias  (cicatricial or paralytic  type)  and recurrent  cases are included.

Operative  technique:   The   idea   of   the tension free repair of anterior  abdominal wall recurrence, symptoms.3

reducibility     and     presenting hernia  depends  on the followings: (1) Proper dissection of the sac. (2) Proper  identification The indications of incisional hernia repair range  from  cosmoses, pain  and  discomfort to   irreducibility,  narrow   neck   and  history of recurrent subacute  intestinal obstruction, whereas   strangulation and  obstruction  pose an absolute  indication for surgery.s

At present, different operative techniques of hemioplasty are used, such as simple  closure, Mayoduplication, prosthetic-implantation in the  onlay  and sublay  techniques, autodermal plasty as well as laparoscopic procedures.9

The introduction of prosthetic mesh repair has  revolutionized  the  repair   of  incisional hernia   and  rendered  obsolete   most  of  the older  methods  of repair,lO the search  for the ideal prostheses  is continuous and oriented towards the use of low weight,  large  pore polypropylene prostheses  which enhances proper tissue integration.ll

Unfortunately, results  of incisional hernia repair   are   disappointing,  recurrence  rates reach  up to  49%  in  open  suture  repair,  and up  to  10%  in  open  and  laparoscopic mesh repair. 12

Continuous efforts  are being held to reach the    optimum    management   of   incisional hernia, so far the most important prognostic factor influencing the outcome is the surgeon's experience.l3

The treatment of incisional  hernia is a current problem in modem surgery. Many important aspects of incisional hernia surgery are yet to be answered, especially the choice of surgical  technique and its adaptation to the individual patient.3

Patients and methods:

The  study  includes  100  cases  of anterior of  the  defect  Figure (1,2). (3)  Reduction of the content. (4) Removal of the excess sac and reclosure  to have an intact peritoneum under the mesh.  (5) Repair  ofthe defect  by double layer  onlay  polypropylene mesh  the  deeper one  is fixed to the free edge  of the defect  by continuous polypropylene (No.  1)  sutures   , the superficial one is inserted  and fixed 3 em from the edge of the defect superificial to the deeper  mesh.

The     postoperative     analysis    included: 

The patients were  followed in the early postoperative by the amount  of the discharge in the suction  drain  and the  condition of the skin flaps.

The    drain    was    removed    in   the    7th postoperative  day  and  the   stitches   after  3 weeks and the patient was re examined every 3 months  as regards the tension  of the repair and  any  sinuses   along  the  suture   line.  The patient  was encouraged to start abdominal exercise  gradually after 3 month.

Results:

Patient  demographics: Hernia reconstruction was performed on 100 patients, 69 females (69%)  and  31 males  (31%)  with incisional  hernias    (cicatricial  or   paralytic type) and recurrent  cases, the mean age of the patients was 38 (range  22-62  years).

The mean  body  mass  index  was  28.2 kg/ m2, the mean length ofthe defect  was 12 em, the mean  width of the defect was 7 em.

Associated       co-morbidities       included diabetes, hypertension, cirrhosis,  bronchial asthma, ischemic heart disease and atherosclerosis as well as obesity Table (1).

Tension   free   repair   of   the   abdominal

Figure    (1):  Dissection   of   the   sac   and identification of the defect.

Figure (3): The deeper mesh is  sutured to the edge of the defect in the external oblique muscle by continous polypropylene sutures.

Figure (2): Proper identification of the edge of the defect is mandatory as the deeper mesh will be sutured to the edge of the defect.

Figure (4): Relatively larger defect repaired by suturing the deeper mesh to the well dissected edge of the external oblique muscle.

Figure (5): Superficial wound infection treated by repeated dressing.

Table (1): Demographic data, Clinical characteristics  and  associated  co­ morbidities.

Table (2): Type, sizeandlength ofthedefect.

defect was performed  on the patients in the following   order:  proper  dissection   of  the sac  and  reduction  of the  content,  reclosure of the defect with preservation of the intact peritoneum,    followed    by    repairing    the defect by double layer onlay polypropylene mesh fixed to the free edge of the defect by continous polypropylene sutures.

The site of the defect was either midline in 65 patients, following Fannestiel's incision in  33  patients,  following  Kocher's  incision in a single patient and following Mcburney's incision in a single patient Table (2).

Reconstruction    was    performed    under clean conditions in 98 patients and clean­ contaminated  in two patients.

The  mean  operative  time  was  2  hours (ranging between 1.5-4 hours).

Postoperative course: The early postoperative course was uneventful in 96 patients (96%). Four patients presented with wound infection, two patients presented with superficial  infection  Figure (5)  which  was properly managed by regular wound dressing for   three   weeks,   the   other   two   patients presented with deep infection and exposed mesh, they were adequately managed by secondary   suturing   after  two   weeks,  the sutures were removed after ten days.

Follow up of the patients was performed every 3 month with maximum follow  up of two years and a minimum of six months, the follow up revealed 8 cases of recurrent hernia (8%), two ofthese cases were associated with obesity, and one case was associated with bronchial asthma.

Discussion:

The surgical treatment of incisional hernia has  changed  rapidly  during  the last  decade with the increasing use of mesh technique and the introduction of laparoscopy. However, many questions concerning mesh type, mesh positioning,  fixation  method  and  operation type    still    remain    unanswered.    Patients with incisional hernia are a heterogeneous population with patient-specific co-morbidity and innate differences (e.g. collagen formation quality). This makes the choice of technique most  suitable  for  each  patient  even  more difficult. 14

The  onlay  technique  is  one  of the established techniques  of  surgical treatment of incisional hernia, it was first described as prefascial prosthetic implantation by Chevrel and Rath.15

In our study we modified the onlay technique for insicional hernia repair by using double onlay polyprolene mesh where the deeper mesh is fixed to the free edge of the external oblique muscle. The superficial mesh was inserted and fixed 3 em from the edge of the defect superificial to the deeper mesh.

This  modification  insured  a tension  free repair of the hernia, the technique is universal and can be applied in both scar and paralytic insicional hernia.

Another  advantage  to  this  technique  is the possibility of its application in different sites, in our study we applied the technique successfully    in   midline    hernia   as   well incisional         hernia    following    Fannestiel's, Kocher's and Mcburney's incisions.

In     concordance    with    the     component separation   technique,   the  onlay  technique with  release of the  external  oblique muscle is successful in large midline and recurrent hernias,  Many surgeons already  recommend the additional application of synthetic mesh in an onlay position to supplement the attenuated layers  of the  anterior  abdominal  wall,2 however the component separation technique requires an undamaged rectus muscle, it also carries  a  risk  of  injuring  the  blood  supply and the nerves that run between the internal oblique and transverse muscle.16

By applying the mesh in an onlay fashion, we avoided the drawbacks in the inlay technique, represented by the induction of extensive  adhesions  of  viscera  if  placed  in a position where they become adjacent to bowel, erosion of the mesh  may then occur into the intestines,2 the onlay technique with muscle  release  can  possibly  substitute  the inlay technique in the management of huge incisional hernia.

The complex sublay technique is limited to the management of midline hernias and, in the lower one-third of this region, the mesh is only protected  from  bowel  by weak  peritoneum carrying the risk of inducing adhesions.17

As   regard   postoperative   complications in our study  four  cases of  wound infection were reported (4%) no postoperative mesh removal  was performed  compared to  a rate of wound healing complications after simple onlay operation ranging between 4% and 26% and an estimated rate of prosthesis removals between 0% and 2.5%.16

Regarding  the  literature,  the  recurrence rates and the percentage of wound healing complications between the onlay and sublay techniques are comparable, the sublay technique  is more  complicated  and requires an experienced and high skilled surgeon.3

The  recurrence  rate in our  present study was 8%, in a comparative study De Vries Reilingh et al, 200416 compared the inlay technique with onlay and sublay in 53 patients with large midline incisional hernia. In this series, the recurrence rate was significantly higher in the inlay technique (44%) compared to 28.3% in the onlay technique and 12% in sublay technique.

The recurrence rates ofthe onlaytechnique indicated in the literature vary between 2.5% and 13.3%. Some recurrences after onlay implantation result from a peripheral mesh dislocation, or an insufficient size of the mesh. So-called "subprosthetic hernia" is possible in cases of the combination of the fascia rupture and laxity ofthe anterior abdominal wal1.3

The  recurrence   rate  in  the   component separation technique was rather inconsistent, in  a  relatively  large  series  of  43  patients, De  Vries  Reilingh  and  colleagues,   200316 were unable to reproduce the good results of Ramirez et al., 199018 and recorded recurrent hernia in 32% of patients at 15-month follow­ up. Reherniation was assumed to be the result of insufficient release of the external oblique muscle at its insertion on the thoracic wall.

DiBello     and    Moore,     199619  used    a modified component separation technique in 35 patients, in 15 patients midline closure was supported by an onlay prosthesis of expanded polytetrafluoroethylene or a Vicryl mesh. Reherniation was found in 9% after a mean followup of 22 months.

The      simple      reconstruction      has      an unacceptably high recurrence rates ranging between   25%   and   55%.   Because   of  these high   rates  after   simple   reconstruction and the development of new tissue-compatible, prosthetic  materials, many surgeons share the opinion   that  an  additional   strengthening of the  frontal  abdominal   wall  by  implantation of allo- and autoplastic material should be obligatory.3

Conclusion:

In our  study, we modified  the  onlay technique for incisional hernia repair by using double  layer onlay polypropylene mesh the deeper  mesh  is fixed  to the free  edge  of the external oblique muscle, , the  superficial one is  inserted   and fixed 3 em from the  edge of the defect superificial to the deeper mesh, this modification provided  a tension free repair of the defect.

The advantages of this technique is its versatility as  it  can  be  applied  to  different sites  of incisional hernia,  also  it works  well with large midline hernias, the study included cicatricial and  paralytic  incisional hernia  as well as recurrent  cases.

The    recurrence   rate    was    acceptably low (8%) with  minimal  postoperative complications, we recorded  (0) mortality  and no cases of mesh removal.

We conclude that onlay repair of incisional hernia with release of the external oblique provides  a good  and versatile alternative for management of large midline  hernias  as well as other sites.

Reference:

1-  Conze J, Binnebosel M, Junge K, et al: Incisional  hernia: How do I do it? Standard surgical   approach.    Chirurg   2010;    8(3):192-200.

2-    Kingsnorth A: The management of incisional hernia. Ann R Call Surg Engl 2006; 88(3):252-260.

3-    Korenkov  M,  Paul  A,  Sauerland  S  et  al: Classification and surgical treatment of incisional hernia. Results of an experts' meeting.   Langenbecks  Arch   Surg   2001;386(1): 65-73.

4-    Wong SY, Kingsnorth AN: Prevention  and surgical  management  of  incisional  hernias. JntJ Surg Invest 2001, 3: 407--414.

5-  Plum DR, Horvath K, Koepsell T: Have outcomes of incisional hernia repair improved with time? A population-based  analysis. Ann Surg 2003; 237(1): 129-135.

6-    DeMaria      EJ,     Moss      JM,     Sugerman HJ:    Laparoscopic            intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Prospective comparison to open prefascial polypropylene mesh   repair.   Surg   Endosc  2000;   14(4):

326-329.

7-    Cassar  K,  Munro  A:  Surgical  treatment  of incisional  hernia.  Br  J  Surg  2002;  89(5):534--545.

8-    O'Dwyer PJ, Courtney CA: Factors involved in abdominal wall closure and subsequent incisional    hernia.    Surgeon.   2003.    1(1):17-22.

9-    Chevrel   JP  ,  Rath  AM:  Classification   of incisional hernias of the abdominal wall. Hernia 2000; 4: 7-11.

10-  Adotey   JM:  Incisional   hernia:  A  review.Niger J Med. 2006; 15(1): 34--43.

11- Schumpelick  V, Klosterhalfen  B, Muller M, et al: Minimized polypropylene mesh for preperitoneal net plasty (PNP) of incisional hernias. Chirurg 1999; 70(4): 422--430.

12-  Chan  G, Chan  CK: A review  of incisional hernia   repairs:   Preoperative    weight   loss and selective use of the mesh repair. Hernia2005; 9: 37--41.

13- Langer  C, Schaper A, Liersch  T, et al: Prognosis    factors    in    incisional    hernia surgery:   25  years'   of  experience.   Hernia 2005, 9:16-21.

14-  Andersen  LP, Klein  M,  Gogenur  I,  et  al: Long-term recurrence and complication rates after incisional hernia repair with the open onlay technique. BMC Surg 2009; 28: 9--6.

15-  San Pio  JR, Damsgaard  TE, Momsen D, et al: Repair of giant incisional hernias with polypropylene mesh: a retrospective study. Scand  J  Plast  Reconstr  Surg  Hand  Surg 2003;37: 102-106.

16- De Vries Reilingh TS, van Goor H, Rosman C, et al: ''Components  separation technique" for the repair oflarge abdominal wall hernias. JAm Call Surg 2003; 196(1): 32-37.

17- Fernandez  RL, Garcia JS, Ortego PD, et al: Tissucol application in dermolipectomy  and incisional  hernia  repair. Jnt Surg 2001;  86:240-245.

18- Ramirez     OM,     Ruas     E,     Dellon     AL: 'Components  separation' method for closure of abdominal-wall  defects: An anatomic and clinical study. Plast Reconstr Surg 1990; 86:519-526.

19- DiBello JN, Moore lli: Sliding myofascial flap of the rectus abdominis muscle for the closure of  recurrent ventral  hernias.  Plast Reconstr Surg 1996; 98: 464-469.