Open Mesh Repair of Incisional Hernia Using a Sublay Technique: Long‐term Follow‐up

Abstract

The article by Dr. Kurzer and colleagues reports more than 100 consecutive patients with incisional hernias repaired with a sublay mesh technique. The outcome is excellent regarding postoperative complications (seromas, abdominal wall discomfort, recurrences). In congruence with the Swedish study cited, a surprisingly large proportion of incisional hernias followed incisions often regarded as being associated with a very low rate of incisional hernia (e.g., gridiron, Pfannenstiel, and subcostal incisions). The operative technique is described in detail concerning what are probably the crucial steps with a sublay mesh technique and seems to have been meticulously followed. It is stated that a standard-weight polypropylene mesh was used, probably reflecting the authors’ sound judgment that the method of repair is more important for the outcome than the trade name of the mesh. Results in this study challenge the concept of incisional hernias recurring late after mesh repair. Placing the mesh with wide overlap may then be important. The method of suturing the aponeurosis to the mesh in case the midline cannot be closed without tension has previously rarely been described. It is a method commonly used in Sweden. and it is attractive because further trauma to the abdominal wall, often necessary when insisting on closure of the midline, is thus avoided. That a mesh should be used for incisional hernia repair seems obvious as results have been poor with suture repair. The questions whether the mesh repair should be laparoscopic or open and if open whether the mesh should be placed in a sublay or an onlay position cannot be answered from this study. The discussion in this article on the subject, however, is highly erudite. The problem is that those questions cannot be answered at all today because randomized control studies are lacking. While awaiting results from such studies we mainly rely on clinical series presented. At best, then, we can presume that these results can be reproduced if the operative technique described is followed. This is a thorough presentation that sets a good standard on how to conduct and present studies on incisional hernia repair that could be used in randomized trials. How is more knowledge to be achieved on how to repair incisional hernia? One difficulty with randomized control studies in this field is that participating surgeons are often familiar with, or interested in, only one of the methods studied. One answer might be expert-based randomized studies; that is, patients are randomized to surgeons with expert knowledge of the methods to be scrutinized. Another possibility may be clustered randomized studies; in other words, results are compared in prospective studies among centers specializing in different methods of incisional hernia repair.