Interposition of the omentum and/or the peritoneum in the emergency repair of large ventral hernias with polypropylene mesh

Abstract

BackgroundVentral and incisional hernias are common surgical problems and their repairs are among the common surgeries done by a general surgeon. Repair of a large ventral hernia is still associated with high postoperative morbidity and recurrence rates. No single approach to ventral hernia repair will be the best choice for all patients. Large ventral hernias are often better approached with open surgery but may still be problematic when the defect is too wide for primary fascial closure to be achieved, as this leaves mesh exposed, bridging the gap. Techniques for incisional hernia repair have evolved over many years, and the use of mesh has reduced recurrence rates dramatically. The use of polypropylene mesh is reported to be associated with long-term complications such as severe adhesions and enterocutaneous fistula, which occur more commonly if the mesh is applied intraperitoneally with direct contact of the serosal surface of the intestine. Composite meshes containing expanded polytetrafluoroethylene (ePTFE) have been used recently; their major drawbacks lie in their high cost, inferior handling characteristics, and poor incorporation into the tissues. Although several studies have clearly demonstrated the safety and efficacy of prosthetic mesh repair in the emergency management of the incarcerated and/or strangulated inguinal and ventral hernias, however, surgeons remained reluctant to use prosthetics in such settings. PurposeThe aim of this work was to evaluate the effectiveness and safety of placing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in the emergency repair of large ventral hernias using on-lay polypropylene mesh whenever complete tension-free closure of the abdominal wall was impossible. Patients and methodsThis study was carried out on all patients with large ventral hernia presented to the Gastrointestinal Surgery Unit, Main Alexandria University Hospital in an emergency situation during the period from October 2005 till October 2012. All patients were treated by placing the omentum and/or the peritoneum of the hernia sac between the viscera and the mesh whenever complete tension-free closure of the abdominal wall was impossible. Some patients necessitated removal of previous meshes and resection-anastomosis of the non-viable bowel prior to mesh repair. Those who underwent complete closure of the abdominal wall without tension prior to mesh repair were excluded from the study as there was no need for interposition of the omentum and/or peritoneum. All patients' data, surgical procedures, complications and follow-up were collected, reviewed and analyzed. After approval of local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were informed well about the operative procedure and use of prosthetic mesh and an informed written consent was obtained from every patient before carrying the procedure. ResultsBetween October 2005 and October 2012; 105 patients (13 males and 92 females) with incarcerated and/or strangulated large ventral hernias were operated upon in the Gastrointestinal Surgery Unit, Main Alexandria University Hospital using an onlay polypropylene mesh. Their age ranged from 37 to 83 years with a mean of 59.3 + 11.7 years. The hernia was para-umbilical in 5 patients (4.8%), incisional in 22 patients (21%) and recurrent in 78 patients (74.3%). The recurrent hernias were recurrent para-umbilical hernias in 56 patients and recurrent incisional hernias in 22 patients. Resection anastomosis of non-viable, devitalized or injured small intestine during removal of adherent previous meshes was performed in 19 patients (18%). Hospital stay ranged from 2 to 13 days with a mean of 3.57 + 1.6 days. There was one perioperative mortality. Complications were encountered in 28 patients (26.7%) and included wound infection with delayed wound healing in 6 patients, seroma formation in 12 patients, chest infection in 8 patients and deep vein thrombosis in 2 patients. Follow-up duration ranged from 13 to 80 months with a mean of 46.8 + 20.3 months. ConclusionPlacing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in repair of incarcerated and/or strangulated large ventral hernia using on-lay polypropylene mesh is cost-effective and safe even with resection anastomosis of small intestine.