Mesh Repair Of Incisional Hernia Research Articles

Management of Incisional Hernia by Preperitoneal Mesh Repair : A Prospective Study in Rural Population

The incidence of incisional hernia in literature is 2- 11% following all laparotomies and it is a source of morbidity and requires high health care costs. This study was undertaken to assess the magnitude of various factors leading to development of this condition & to evaluate the technique of preperitoneal mesh repair of incisional hernias with regards to post operative complications, hospital stay and recurrences, if any. This was a prospective study of 100 cases of incisional hernia who attended our OPD from May 2008 to May 2010. In the present study, preperitoneal mesh repair had excellent long-term results with minimal morbidity. Comparing other types of mesh repair, the preperitoneal mesh repair is the gold standard treatment for incisional hernia. Key words: Incisional hernia, Preperitoneal, Mesh repair

Long term outcome and quality of life after open incisional hernia repair - light versus heavy weight meshes

BackgroundMesh repair of incisional hernia is superior to the conventional technique. From all available materials for open surgery polypropylene (PP) is the most widely used. Development resulted in meshes with larger pore size, decreased mesh surface and lower weight. The aim of this retrospective non randomized study was to compare the quality of life in the long term follow up (> 72 month) after incisional hernia repair with "light weight"(LW) and "heavy weight"(HW) PP meshes.Methods12 patients who underwent midline open incisional hernia repair with a HW-PP mesh (Prolene® 109 g/m2 pore size 1.6 mm) between January 1996 and December 1997 were compared with 12 consecutive patients who underwent the same procedure with a LW-PP mesh (Vypro® 54 g/m2, pore size 4-5 mm) from January 1998. The standard technique was the sublay mesh-plasty with the retromuscular positioning of the mesh. The two groups were equal in BMI, age, gender and hernia size. Patients were routinely seen back in the clinic.ResultsIn the long term run (mean follow up 112 ± 22 months) patients of the HW mesh group revealed no significant difference in the SF-36 Health Survey domains compared to the LW group (mean follow up 75 ± 16 months).ConclusionsIn this study the health related quality of life based on the SF 36 survey after open incisional hernia repair with light or heavy weight meshes is not related to the mesh type in the long term follow up.

Hospital-level variability in incisional hernia repair technique affects patient outcomes

Mesh placement during ventral incisional hernia repair has been shown to result in superior outcomes; however, significant variation persists in the adoption of this technique. We performed a multi-institutional study to understand how variation in surgical technique influences outcomes. This study is a retrospective, facility-level analysis of incisional hernia repairs performed at 16 veteran's administration medical centers between 1997 and 2002. Operative notes and a postoperative course were physician-abstracted from the medical record. Hospital rates for the type of hernia repair, mesh placement, and recurrence were calculated. Spearman's correlation and generalized linear models were performed. A total of 1,612 incisional hernia repairs with a median follow-up of 66.2 months were included in the study. The mean rate of mesh implantation was 63.7% but ranged from 37.5% to 90%. The 5-year recurrence rate was 25.6% and ranged from 16.0% to 38.4%. The rate of mesh use for the incisional hernia repair at the hospital level was associated significantly with the hospital recurrence rate for all cases (R(2) = .27; P = .04) and elective cases (R(2) = .31; P = .02). For every 10% increase in the rate of mesh placement, a corresponding 3.1% decrease was noted in the recurrence rates (P = .001). The hospital rate of mesh use was not associated significantly with rates of complications or patient satisfaction. Hospitals that adopted a higher rate of mesh repair for incisional hernia repairs had lower recurrence rates. These data support that the efficacy of mesh repair previously proven in clinical trials is highly translatable to effective practice in the field. Continued studies on the attributable risk of complications to mesh placement are ongoing.

Polypropylene mesh repair of incisional hernia after kidney transplantation: Single-center experience and review of the literature

Incisional hernia after kidney transplantation increases patient morbidity and impacts quality of life. Reports of hernia mesh repair after kidney transplantation are rare; thus, the benefit of mesh hernioplasty in transplanted patients is assumed. However, it is also assumed that transplant patients are susceptible to incisional and mesh infections. Between January 1, 2005 and December 31, 2010, we performed 1067 kidney transplantations. Twenty-eight patients developed incisional hernias (2.6%), and mesh repair was performed in 20 of them (8 women, 12 men; median age 59.5 years, range 43 to 68 years). We retrospectively studied this latter group. We also reviewed the literature regarding the results of this treatment. Postoperative mortality was zero, but postoperative wound bleeding led to surgical revision in 1 patient. Wound infection did not occur. During the follow-up period we observed 4 hernia recurrences (20%). In conclusion, our retrospective study and review of the literature confirmed the safety and low incidence (1.1% to 3.8%) of mesh hernia repair in chronic immunosuppressed patients after renal transplantation, which has a minimal risk of wound infection and no higher risk of hernia recurrence than in non-transplant patients.

Serum analyses for protein, albumin and IL-1-RA serve as reliable predictors for seroma formation after incisional hernia repair

The aim of this study was to identify potential parameters as predictors for seroma formation after incisional hernia mesh repair. The incidence of postoperative seroma was determined prospectively in 37 patients who underwent incisional hernia repair with lightweight polypropylene-polyglactin composite mesh (Vypro-II®). Postoperative seroma manifestation was related to patient characteristics (gender, age, BMI, comorbidity, nicotine abuse) and to preoperative serum concentration of total protein, albumin, interleukin-1-receptor-antagonist (IL-1-RA), propeptid-III-procollagen, hyaluronan and fibronectin. Ultrasound investigation was performed on postoperative days 1, 2, 3, 8 and 10. Ten patients (27%) developed seroma with a mean volume of 77 ± 88 ml. Higher BMI correlated with increased seroma formation (P = 0.038). In patients with seroma, total protein (67 ± 7 vs 72 ± 4 g/l; P = 0.037), albumin (42 ± 3 vs 40 ± 4 g/l; P = 0.018) and IL-1-RA (1.4 ± 1 vs 0.8 ± 0.6 U/ml; P = 0.048) exhibited significantly altered serum concentrations in comparison to patients without seroma formation. No significant differences were seen in any other parameters. High BMI, lowered preoperative serum concentration of total protein and albumin, and high serum concentration of IL-1-RA are related to an elevated risk for postoperative seroma formation.

Do drainage liquid characteristics serve as predictors for seroma formation after incisional hernia repair?

Though the occurrence of postoperative seroma after incisional hernia repair using mesh reinforcement is very common, little is known about the genesis of seroma formation. The aim of this study was to determine the characteristics of drainage liquid as a potential predictor for the development of seroma after incisional hernia mesh repair. Furthermore, the characteristics of drainage liquid were compared to the characteristics of seroma liquid. The incidence of postoperative seroma associated with pH value, concentration of lactate, total protein, albumin, propeptide-III-procollagen (P-III-P), hyaluronan, fibronectin and IL-1 receptor antagonist (IL-1-RA) in the drainage liquid were prospectively determined in 38 patients who underwent incisional hernia repair by lightweight polypropylene-polyglactin composite mesh (Vypro-II). The findings were compared to the seroma liquid characteristics of those patients who developed a seroma formation. In 11 patients (29%), seroma formation was present after removal of the drainage. We observed significantly elevated mean drainage volume (148 +/- 64 ml vs. 93 +/- 71 ml; P = 0.014) and significantly reduced pH value (7.26 +/- 0.12 vs. 7.41 +/- 0.23; P = 0.016) and IL-1-RA (100 +/- 71 U/ml vs. 145 +/- 108 U/ml; P = 0.016) in the drainage liquid of patients with seroma formation in comparison to patients without seroma formation. In addition, we found significantly altered concentration of lactate (9.8 +/- 2.0 mmol/l vs. 5.5 +/- 1.4 mmol/l; P < 0.001), P-III-P (24 +/- 13 U/ml vs. 89 +/- 79 U/ml; P = 0.045) and fibronectin (0.10 +/- 0.03 g/l vs. 0.24 +/- 0.13 g/l; P = 0.005) in the drainage liquid in comparison to seroma liquid. The pH value of wound solution proves to be a reliable predictor for the subsequent presence of seroma formation. Furthermore, our findings implicate that seroma formation cannot be seen as persistent drainage liquid.

Laparoscopic mesh repair of incisional hernia following right lower quadrant renal transplantation

The development of an incisional hernia after lower quadrant renal transplantation is an infrequent complication, but poses a difficult surgical challenge due to the proximity of the incision to the allograft and the pelvic rim. We describe the first such case of a laparoscopic repair of a recurrent incisional hernia after renal transplantation in the literature.

Enterocutaneous Fistula Presenting with Septicemia 10 Years after Mesh Repair of Incisional Hernia

Incisional hernias are commonly repaired using meshes. There are various studies both in favour of and against the possibility of enterocutaneous fistula formation after mesh repair of incisional hernia. We are reporting on a 52-year-old female who developed an enterocutaneous fistula leading to septicemia 10 years after incisional hernia repair using a polypropylene mesh.

Enterocutaneous fistula due to mesh fixation in the repair of lateral incisional hernia: a case report

Enterocutaneous fistula following mesh repair of incisional hernia is usually due to mesh erosion of the underlying viscus and presents late. We describe an early enterocutaneous fistula due to an unusual but a potential mode of bowel injury during mesh fixation. This case is reported to emphasize the need for greater attention to the technique of mesh fixation. We suggest laparoscopic guidance to prevent this serious complication in lateral Incisional hernias with ill defined edges of the defect.

Suture versus staple for fixation of mesh in incisional hernia repair

The incidence of incisional hernia has been reported to be between 11 and 20% in patients post laparotomy and carries the risk of pain, incarceration and strangulation. Prosthetic mesh for incisional hernia repair has been shown to be superior to suture repair. The recurrence rate of primary mesh repair of incisional hernias has been reported to be as high as 38%. This experimental study in euthanised rats aims to compare the fixation strength of mesh using sutures and surgical staples. Forty euthanised adult male Sprague–Dawley rats were used for midline laparotomy incisions and repair of the abdominal wall carried out using polypropylene mesh anchored using either skin staples or Prolene sutures. An intra‐abdominal expander device was inserted into the abdomen and inflated to measure ‘burst pressure’. Pressure changes and surgical time were recorded. There was no statistically significant difference (P = 0.83) in the pressure required to disrupt the mesh fixation between the two groups, 101 ± 12 mmHg in the suture group versus 102 ± 14 mmHg in the staple group. Staple fixation was 9.7 times faster compared with suture fixation, 291 ± 42 s for suture versus 30 ± 8 s for staples (P &lt; 0.001) (power = 94%). The immediate strength of fixation is equal using both sutures and staples, however staple fixation is faster. Mesh migration due to inadequate fixation using either method is unlikely to cause early failure, however suture and staple ‘cut out’ during early movement may explain this.

Adverse Events, Quality of Life, and Recurrence Rates after Laparoscopic Adhesiolysis and Recurrent Incisional Hernia Mesh Repair in Patients with Previous Failed Repairs

The aim of this study was to determine the impact of laparoscopic adhesiolysis and mesh repair on adverse event rates, quality-of-life (QoL) scores, and recurrence rates in patients with recurrent incisional hernia after failed repairs after multiple laparotomies. Data on consecutive patients were included prospectively. Recurrent incisional hernia was defined as a fascia defect > 5 cm. Adhesions were classified according to time needed for lysis. A standardized repair with IP polytetrafluoroethylene mesh, transabdominal sutures, and tacks was developed by the surgeons during a pretrial routine. QoL was assessed by the Gastrointestinal Quality of Life Index (GIQLI) before operation and at 24-month followup. Values are median (range). There were 85 consecutive patients aged 55 years (range 29 to 93 years); 45% were men; body mass index, 31 (range 23 to 39); American Society of Anesthesiologists grade I: 27%, II: 70%, III: 2%; comorbidity, 75%; previous laparotomies; 5 (range 2 to 18); previous colectomy, 87%; previous failed repairs, 4 (range 2 to 15); previous mesh repair, 98%; and midline hernia site, 98%. Fascia defect was 255 cm(2) (range 48 to 416 cm(2)), mesh size, 600 cm(2) (range 285 to 884 cm(2)), and operating time 145 minutes (80 to 210 minutes). There was one conversion. Length of stay was 2 days (1 to 9 days). A 15.2% adverse event rate included 1% port-site cellulitis, 7% seroma, and 7% persistent pain. Hernia recurrence rate was 3.5% at 41-month (range 24 to 61 months) followup. GIQLI total scores were significantly improved at followup (98 versus 116; p < 0.001). Domain GIQLI scores were improved at followup for symptoms (54 versus 63; p < 0.001), emotional function (12 versus 16; p < 0.001), and physical function (15 versus 21; p < 0.001). Laparoscopic adhesiolysis and recurrent hernia mesh repair resulted in a low rate of adverse events, a substantially improved health-related QoL, and a risk of recurrence similar to the rates associated with first-time hernia repair.

Impact of antimicrobial prophylaxis duration on wound infection in mesh repair of incisional hernia – preliminary results of a prospective randomized trial

BACKGROUND: Surgical site infections are the second most common cause of nosocomial infections. Antibacterial prophylaxis in clean surgery is controversial; nevertheless in surgery for incisional hernia with mesh it is recommended. This study was undertaken to evaluate the impact of the duration of antimicrobial prophylaxis on the rate of wound-related infections in patients undergoing repair of incisional hernia with polypropylene mesh and in whom closed suction drains were used. Evidence-based data on this subject are lacking. METHODS: A prospective randomized study was conducted to analyze 44 consecutive patients undergoing elective surgery for abdominal incisional hernia requiring polypropylene graft and subcutaneous drains. Two patients who had inadvertent bowel entry were excluded. The remaining patients were randomly allocated into two groups: Group 1 (21 patients) was given a single dose of preoperative antibiotic prophylaxis. Group 2 (21 patients) had antibiotic cover pre- and postoperatively until the drain tubes were removed. The primary outcome measure was the occurrence of wound infection as defined according to the criteria of the Center for Disease Control. RESULTS: The groups were well matched for all variables studied. The occurrence of wound infection was 19% in Group 1 and in 33.3% in Group 2. This difference did not reach statistical significance. Most infections were mild (cellulitis and infiltrate), only in two patients purulent discharge occurred. Removal of mesh was required in one of these patients in group 1. CONCLUSIONS: Regardless of the duration of antibiotic prophylaxis, no statistically significant difference was found in wound-related complications in patients undergoing elective repair of incisional hernia with mesh and in whom subcutaneous drainage was employed. Nevertheless, a trend towards a better outcome in the single dose preoperative antimicrobial prophylaxis regimen seems to emerge. Larger studies are needed to establish firm, evidence-based guidelines.

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

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.

Abdominal lipectomy and mesh repair of midline periumbilical hernia after bariatric surgery: How to spare the umbilicus

Abdominal lipectomy is becoming an increasingly common surgical procedure in patients with esthetic deformities resulting from massive weight loss induced by bariatric surgery. Sometimes a midline incisional hernia coexists with the pendulus abdomen. Herein presented is a technique to perform a retromuscular mesh repair of the incisional hernia while sparing the umbilicus. The abdominal lipectomy with concomitant retro-muscular mesh repair of a midline incisional hernia is done sparing the vascular supply of the umbilicus on one side only. 5 consecutive women with pendulus abdomen resulting from bariatric surgery-induced massive weight loss and concomitant midline incisional hernia underwent abdominal lipectomy and incisional hernia mesh repair. Mean BMI was 28.6 kg/m2 (range 26-35), one patient was a smoker, and another had type 2 diabetes requiring oral hypoglycemic agents. Two patients had had a previous incisional hernia repair with intraperitoneal mesh. One patient had partial necrosis of the umbilicus and another experienced necrosis of only the epidermis that recovered fully. The umbilicus can be safely spared during abdominal lipectomy with concomitant midline incisional hernia mesh repair. Recurrent incisional hernia and common risk factors for wound healing such as diabetes and obesity increase the risk of umbilical necrosis.

Robot-assisted laparoscopic mesh repair of incisional hernias with exclusive intracorporeal suturing: a pilot study

The da Vinci robot laparoscopic incisional hernia repair with intracorporeal suturing may offer an alternative to transabdominal sutures and tackers. From 2003 to 2005, 11 patients (median age, 71 years; median body mass index [BMI], 28) with small and medium-sized incisional hernias (median fascial defect, 19.6 cm2) were treated with the da Vinci robot system using intracorporeal mesh fixation with interrupted sutures. This pilot study aimed to assess the feasibility and report the morbidity with special reference to postoperative pain and long-term recurrence. The median operative time was 180 min. There was no conversion to open or standard laparoscopy and no postoperative mortality. The overall morbidity rate was 27%. One patient underwent reoperation on postoperative day 3 for peritonitis secondary to small bowel injury. The median visual analog pain score on postoperative day 1 was 3. Seven patients (63%) needed parenteral paracetamol until postoperative day 2. The median hospital stay was 3 days. During a median follow-up period of 25 months, no patient experienced recurrent hernia. One patient had a trocar-site herniation at 6 months. No patient experienced chronic suture site pain or discomfort. This is the first report of robot-assisted laparoscopic incisional hernia with exclusive intracorporeal suturing for mesh fixation in humans. The findings show that this technique is feasible and may not be associated with chronic postoperative pain. Further evaluation is needed to assess the benefit to the patient, but this investigation may be the basis for a future, prospective, randomized study.

Laparoscopic mesh repair of incisional hernia: an alternative to the conventional open repair?

Tension-free incisional hernia repair using alloplastic material increasingly replaces conventional repair techniques. This change resulted in a decreased recurrence rate (50% vs. 10%, respectively). Recently, laparoscopic approaches for the intraperitoneal tension-free mesh application have been introduced. The decreased trauma at the incision site and the reduction in wound infections appear to be the main advantages. The aim of the present study was to evaluate the early and long-term complications as well as patients' contentment. Laparoscopic hernia repair with intraperitoneal polytetrafluroethylene (PTFE) mesh implantation was performed on 62 patients at the Klinikum Grosshadern between 2000 and 2005 (29 males, 33 females age 60.7). Intra- and postoperative complications were registered prospectively and retrospectively analyzed. In addition, 57 patients were evaluated for recurrence, postoperative pain and patient contentment (median follow-up 409 days). A low complication rate was observed in our patient collective. One trocar bleeding occurred. Three patients presented with wound hematoma. The recurrence rate was 8% (2/25). Sixty-two percent of the patients were free of complaints postoperatively. Eighty-five percent would once again choose the laparoscopic approach for incisional hernia repair. The laparoscopic technique was associated with a low recurrence rate, a small rate of wound infections and high patient comfort. Thus, the laparoscopic approach for mesh implantation appears to be a safe and effective method for the treatment of incisional hernias. The efficiency for laparoscopic intraperitoneal mesh implantation, however, should be further evaluated within a prospectively randomized multicenter trial.

Improving Outcomes in Hernia Repair by the Use of Light Meshes—A Comparison of Different Implant Constructions Based on a Critical Appraisal of the Literature

Despite convincing advantages offered by meshes, their use in hernia surgery remains controversial because of fears concerning the long-term effects of their implantation. To improve biocompatibility, a large variety of newly developed light meshes has been introduced to the market. This overview of the literature aimed to establish whether absolute material reduction (g per implanted mesh), use of absorbable components, and coating by inert materials are evidence-based ways to improve biocompatibility of meshes. A review of the current English and German language literature on the outcome of groin und incisional hernia mesh repair was performed. Both basic research and clinical trials were used as sources of data. Meta-analyses and randomized controlled trials were given priority and were referred to whenever possible. Operative technique was an independent prognostic factor for the clinical outcome. Mesh construction and composition as characterized by pore size and filament structure appeared to be more important determinants of foreign body reaction after implantation than absolute material reduction of 1 g or more per implant. No data exist about an oncogenic effect of alloplastic materials in humans, but disturbed fertility in animal studies remains an issue of concern and should be further investigated. According to data from current randomized controlled trials and retrospective studies, light meshes seem to have some advantages with respect to postoperative pain and foreign body sensation. However, their use is associated with increased recurrence rates. Light meshes offer no advantages with respect to alleviating severe chronic groin pain. At the same time, experimental data reveal that material composition and mesh structure may significantly affect foreign body reaction.

The use of mesh and collagen in incisional hernias

Dear Editor We read with much interest the article by Vidovic et al., titled “Factors aVecting recurrence after incisional hernia repair [1]”. We fully agree with the authors’ conclusion that it is important to become familiar with the risk factors for recurrence of incisional hernia to eliminate or decrease recurrence, but we have a few remarks concerning the article. The authors claim that the routine use of synthetic mesh is not justiWed because of its potential for complications, and that the results of sutured repair of small to medium-sized hernias are satisfactory. However, according to a well-conducted randomized controlled trial that compared suture versus mesh repair of incisional hernia in patients with a primary or Wrst-time recurrent incisional hernia, the conclusion was that the routine use of mesh is superior to suture repair for both small and large incisional hernias, and the use of mesh repair results in lower recurrence rates. Mesh reduces the morbidity and costs associated with incisional hernias. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). Hence, concerning the potential for complications in the mesh repair group, 17% had a complication, compared with 8% in the suture repair group (P = 0.17), not a statistically signiWcant diVerence [2]. The authors also did not discuss collagen metabolism disorders in hernia patients. Collagen disorders play an important role in the development of inguinal hernia [3]; impaired proportions result in tissue alterations, and are one of the factors that lead to hernia formation. Collagen plays an important role in the pathogenesis of incisional hernias and is not mentioned. A recent study, conducted in our department, comparing the qualitative and quantitative aspects of total and types I and III collagen samples of linea alba aponeurosis in patients with hernias on the anterior abdominal wall, including incisional ones, and from cadavers without hernias, showed that individuals with hernia have a small amount of total and type I collagen. The amount of total collagen was 18.05% smaller and type I collagen was 20.50% smaller in patients with hernias (P < 0.05) [4]. The results of these and other studies [5] indicate a relationship between incisional hernias and collagen disorder. In the evaluations of incisional hernia repair we should never forget the important role of collagen imbalance in the pathophysiology of hernia formation. The use of mesh should be increasingly encouraged to avoid unnecessarily high rates of recurrence.

Incisional hernia: challenge of re-operations after mesh repair

The widespread use of meshes for the repair of incisional hernia is currently followed by an increasing number of re-operations. The incidence of incisional hernia recurrence after mesh repair varies between 3 and 32%. The problem of mesh failure and options for another surgical intervention seem rather unattended. We present our experience of 77 re-operations after previous mesh repair that were performed between 1995 and 2004 out of a total of 1,070 operations for incisional hernia. The retrospective analysis focused on recurrence in relation to location, material of the previous mesh repair and the surgical procedure to resolve the problem. The locations of the preceding meshes were epifascial as onlays (n=23), retromuscular as sublays (n=46), within the defect as inlays (n=6) or intraperitoneally (n=2). The direction of the incision was vertical medial (n=41) or horizontal crossing the linea semilunaris (n=36). Recurrences after median incisional hernia mesh repair mainly occurred at the cranial border of the mesh subxiphoidal. Except for two patients, all recurrences manifested at the margin of the enclosed mesh. Re-operation after previous mesh repair is a surgical challenge. The type of revision procedure has to consider the position and material of the previous mesh. In our clinic recurrences, heavyweight polypropylene meshes were mostly treated with mesh exchange and lightweight polypropylene meshes could be treated by extension with a second mesh. In contrast to suture techniques, deficient mesh repairs are more evidently related to technical problems.

Combined fascia and mesh repair of incisional hernias

Incisional hernia is a relatively common complication following abdominal operations. Due to high recurrence rates following primary suture, a prosthetic mesh is now usually used to repair the hernia. Several different types of repair are described. A combined fascia and mesh technique avoids opening the peritoneal cavity and potential damage to bowel. This study describes results of this technique. Consecutive patients undergoing the operation were contacted to assess freedom from recurrence and satisfaction with results. Some 34 patients underwent 36 incisional repairs. Of the 34 patients 21 were men and 13 were women with a median age of 69 years (range 31-86 years). The causative incisions were midline (30), Kochers (2), Pfannesteil (2) and transverse (2). The median time spent in hospital was three nights (range 1-14 days). Two patients developed seromas, another complained of pain soon after operation, one patient developed a superficial wound infection another developed a tender drain site which required exploration. One patient with significant co-morbidity died 13 days postoperatively from multiorgan failure. Freedom from recurrence of the hernia was 91% at 5 years. However patient survival was only 70% at 5 years. This technique is associated with low postoperative morbidity and a low recurrence rate. Patients presenting with incisional hernias have a poor long-term prognosis which needs to be borne in mind when planning intervention.