Mechanisms of Ventral Hernia Recurrence after Mesh Repair and a New Proposed Classification

Abstract

The incidence of recurrence after ventral hernia repair is prohibitive. In this article, we objectively address the reasons for the recurrence as reported in the literature andproposecorrectivemeasuresplusanewclassification of recurrence to standardize and encourage reporting. Ventral hernia repair is a commonly performed operation. In the past 4 decades, the surgical technique for ventral hernioplasty has gone through 3 stages. Before 1960, most were repaired by tissue approximation, which was accompanied by a recurrence rate of 30% to 40%. 1-4 This was noticed in particular with large defects causing the fascia to be under additional tension after closure. It became apparent that a prosthetic material was required to reinforce the repair or bridge the tissue defect. The use of a prosthetic mesh for ventral hernia repair first occurred in the early 1960s, when Usher 5,6 described the usefulness of a knitted polypropylene meshforrepairofcomplexinguinalherniasandanterior abdominal wall hernias. Prosthetic mesh improved the recurrence rate (5% to 20%), yet was associated with a higher risk of seroma, hematoma, and tissue necrosis from extensive dissection. Sitzmann and McFadden 7 reportedreductionoftherecurrencerateto2.5%whenusing internal retention sutures with mesh, and the debate about an optimal prosthetic technique of repair commenced. Laparoscopic ventral hernia repair has been recently introduced. The technique is currently popular, but the followupisinsufficienttoestablishadefinitiveappraisal. But further insight into mechanisms of recurrence may be gained by this new approach and will be included. The high recurrence rate after repair of a ventral hernia has been a concern for all surgeons experienced in this field. Ventral hernia recurrence creates morbidity, prolonged hospitalization, the need for reoperation in most circumstances, occasional mortality, and increased cost to the patient. 8 A few publications specifying a mechanismofrecurrenceemphasizefurthertheneedfor accurate reporting and careful scrutiny of patients requiring reoperation for a ventral hernia. METHODS A Medline literature review was conducted on papers in English published after 1966. The data were collected using an Excel spreadsheet and Microsoft Access database software. Exclusion criteria included: published series with less than 10 patients; series using a nonprosthetic repair; unclear descriptions of technique used; series with parastomal hernias; series with transplant patients or patients receiving peritoneal dialysis; and series withacute(traumatic)lossoftheabdominalwall.Transplant and dialysis patients were often immunosuppressed, creating an additional wound-healing variable, andpatientswithabdominalwalltraumaoftenhadmas