Traitement des éventrations de la paroi abdominale

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Incisional hernias occur in about 13 to 20 % of patients undergoing abdominal surgical procedures. They entail a large financial burden with high cumulative rate of reoperative repairs. Development of minimally invasive surgery got rid of occurrence of large hernias but might induce a new concept, the limited port-site hernias. Anatomical reconstitution with closure of linea alba by suture or autoplasty has been shown to have a high recurrence rate. Tension free obturation of the defect with a prosthetic mesh is becoming the procedure of choice for any hernia whatever the size. The recurrence rate has been reduced to less than 10 %. Non absorbable synthetic biomaterials are widely used. Macroporous meshes (polypropylene, polyester) have a high adhesion rate unsuitable for direct contact with the bowel as opposed to microporous one (e PTFE). Newer composite biomaterials with an anti-adhesive inner surface are available for intraperitoneal placement. Current sites of mesh implantation are intraperitoneal, preperitoneal, retro muscular-prefascial, pre muscular-prefascial. Mesh reinforcement is also indicated for repair of muscle-splitting transverse or sub-costal hernias. In case of emergency laparotomy for intestinal obstruction or planned surgical procedure in patient presenting with incisional hernia, synchronous repair with mesh is mandatory. Non absorbable mesh can be used in the presence of open bowel. In a grossly contaminated field, absorbable mesh is advisable. The most commonly reported complication is seroma formation which generally resolved spontaneously. Infection is the second most common complication. Incidence, treatment and outcome depend on the nature of the biomaterial. In case of repeated repair for recurrence, a procedure different from that previously used with a prosthetic reinforcement must be performed. Laparoscopic approach to incisional hernia includes intraperitoneal placement of a composite biomaterial overlapping the margins of the defect without any attempt of anatomical reconstitution, nor resection of the hernia sac. Mesh is secured with a combination of non absorbable sutures through the abdominal wall and laparoscopically placed staples. The benefits are a decrease in surgical morbidity and hospital stay. Recurrence rate is reported to be equal or less than in the open repair. Drawbacks are a longer operative time, frequent difficulties of performing adhesiolysis with risk of bowel injuries and persistance of cutaneous changes. Laparoscopic approach is mainly indicated for small sized hernias with a reductible content.