Midline Incisional Hernia Research Articles

The anterior rectus abdominis sheath flap for fascial closure in burst abdomen and midline incisional hernia

Objectives The aim of this study is to evaluate the effect of using the anterior rectus abdominis sheath flap in the repair of burst abdomen and midline incisional hernia. Background Complex abdominal wall hernias can be challenging for the reconstructive surgeon. The use of autologous tissue is preferable when possible. This repair entails a single fascial incision releasing the anterior rectus sheath as a turnover flap for abdominal wall reconstruction. This allows large defects to be closed with autologous tissue alone in a two-layer fascial repair in a vest-over-pants manner in a simple, straightforward surgical approach. Materials and methods Thirty participants requiring open abdominal management over a 26-month period were reviewed who underwent the anterior rectus abdominis sheath flap which released by lateral incision that meeting in midline as open book closing the defect ± the mesh. Hospital and office-based charts were reviewed. Results Thirty patients included in this study have risk factors such as anaemia (14:46.7%), malnutrition (11:36.7%), smoking (17:56.7%), obesity (16:53.3%), malignancy (17:56.7%), diabetes (8:26.7%) and chest complications (chronic obstructive pulmonary disease) (12:40%), with the cause of primary lesion divided into intestinal obstruction (6:20%), gastrointestinal tract malignancy (10:33.34%), miscellaneous (gynaecological and urological) (7:23.33%) and traumatic laparatomy (7:23.33%). Postoperative complications were wound infection (6:20%), seroma (5:16.6%), skin necrosis (3:10%), recurrence (1:3.3%), haematoma (1:3.3%) and no fistula. The average length of follow-up was 6-26 months. Conclusion The use of the anterior rectus abdominis sheath flap is an important technique for fascial closure in burst abdomen and midline incisional hernia; it is a simple and natural technique and provides a fascial closure with low recurrence and acceptable complications.

Sublay versus underlay in open ventral hernia repair

BackgroundThe ideal location for mesh placement in open ventral hernia repair (OVHR) remains under debate. Current trends lean toward underlay or sublay repair. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer surgical site infections (SSIs) and recurrences. Materials and methodsA multi-institution database of all OVHRs performed from 2010 to 2011 was accessed. Patients with mesh placed in the sublay or underlay position and at least 1 mo of follow-up were included. Primary outcome was SSI. Secondary outcome was hernia recurrence. Multivariate analysis was performed using logistic regression for SSI and Cox regression for recurrence. Subgroup analysis of elective, midline ventral incisional hernias was also performed. ResultsOf 447 patients, 139 (31.1%) had a sublay repair. The unadjusted analysis showed no difference in SSI and lower recurrence using sublay compared with underlay. On multivariate analysis, there was no difference in SSI using sublay compared with underlay (odds ratio 1.5, 95% confidence interval [CI] 0.8–2.8). Recurrence was less common with sublay (hazard ratio 0.4, 95% CI 0.2–0.8). On subgroup analysis of elective, midline incisional hernias only (n = 247), there were more SSIs with sublay compared with underlay repair (28.0% versus 15.1%, P = 0.018); however, there was no difference in major SSI (sublay 9.3% versus underlay 5.8%, P = 0.315). There were fewer recurrences using sublay repair compared with underlay repair (10.7% versus 25.0%, P = 0.010). ConclusionsIn this multi-center, risk-adjusted study, sublay repair was associated with fewer recurrences than underlay repair and no difference in SSI. Randomized controlled trials are warranted to validate these findings.

A stepwise approach based on a rational use of components separation and double mesh prosthesis for incisional hernia repair

We aimed to evaluate the results of a protocol for a tension-free reconstruction of the abdominal wall in midline incisional hernia repair, based on the rational association of components separation and prosthesis, independently of the hernia size. A total of 100 consecutive patients with midline incisional hernias were prospectively included in the study. Three groups according to the transverse diameter of the defect [group A (<4 cm, N = 18), group B (4-10 cm, N = 59), and group C (>10 cm, N = 23)] were identified. Components separation was necessary in 54% of the patients: 16.7% (3/18) in group A, 59.3% (35/59) in group B, and 69.6% (16/23) in group C. Complete tension-free reconstruction was achieved in 87% of the patients: 94.4% (17/18) in group A, 91.5% (54/59) in group B, and 69.6% (16/23) in group C. Overall morbidity rate was 21% (21/100) [group A 16.7% (3/18), group B 22% (13/59), and group C 21.7% (5/23)]. Hospital length of stay was 3.7 ± 3.3 days (group A 1.83 ± 1.43 days, group B 3.05 ± 2.11 days, and group C 6.91 ± 4.45 days). Median follow-up was 25 months (interquartile range 12.25-55.25) with overall recurrence of 2%. A tension-free abdominal wall reconstruction can be achieved in most cases of small and large midline incisional hernia repair, by a stepwise approach based on a rational association of components separation and double mesh prosthesis, with a low morbidity and recurrence rates.

Systematic review and meta regression of factors affecting midline incisional hernia rates: An analysis of 14,618 patients

Systematic review and meta regression of factors affecting midline incisional hernia rates: An analysis of 14,618 patients

Acute inflammatory response in the subcutaneous versus periprosthethic space after incisional hernia repair: an original article.

BackgroundThe acute inflammatory response following mesh implantation has been often evaluated in vitro and in animal models. The aim of this study was to evaluate the acute inflammatory response near the prosthesis in human by analysing some inflammatory indicators.MethodsWe used a cohort of twelve male patients affected by midline incisional hernia, who were admitted for surgical mesh repair. A suction drain was placed between the mesh and rectal muscles whereas, the other one was placed between the subcutaneous tissue and the oblique external sheath. The acute inflammatory response was analyzed by measuring the production of interleukin [IL]-1, IL-10, IL-1ra, C-Reactive Protein (CRP), total proteins, albumin and pH in the drain fluids.ResultsThe dynamics of CRP and ILs production resulted similar in both drainages. Comparing drain over mesh and subcutaneous drain at all times, IL-1 and CRP values always resulted significantly higher in the first one, whereas IL-1ra and IL-10 values were significantly higher in the last one. Total protein and albumin were similar in both drains at all time; only in the drain over mesh fluid, pH values resulted significantly reduced in the fourth post-operative day.ConclusionsOur data showed that an acute inflammatory reaction is present in both sites examined. However, it was significantly higher in the space after mesh implantation.

Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management.

Abdominal wall hernia secondary to open abdomen management represents a surgical challenge. The hernia worsens due to lateral muscle retraction. Our objective was to evaluate if Botulinum Toxin Type A (BTA) application in lateral abdominal wall muscles modifies its thickness and length. A clinical trial of male trauma patients with hernia secondary to open abdomen management was performed from January 2009 to July 2011. Thickness and length of lateral abdominal muscles were measured by a basal Computed Tomography and 1 month after BTA application. A dosage of 250 units of BTA was applied at five points at each side between the external and internal oblique muscles under ultrasonographic guidance. Statistical analysis for differences between basal and after BTA application measures was performed by a paired Student's t test (significance: p<0.05). Seventeen male patients with a mean age of 35years were included. There were muscle measure modifications in all the patients. Left muscle thickness: mean reduction of 1±0.55cm (p<0.001). Right muscle thickness: mean reduction of 1.00±0.49cm (p<0.001). Left muscle length: mean increase of 2.44±1.22cm (p<0.001). Right muscle length: mean increase of 2.59±1.38cm (p<0.001). No complications secondary to BTA or recurrences at mean follow-up of 49months were observed. BTA application in lateral abdominal muscles decreases its thickness and increases its length in abdominal wall hernia patients secondary to open abdomen management.

Single-Center Experience With Parastomal Hernia Repair Using Retromuscular Mesh Placement

BackgroundParastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement. MethodsFrom 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences. ResultsThere were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m2. Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n = 29), lightweight polypropylene (n = 15), or absorbable synthetic mesh (n = 2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11 %) developed a recurrence; three patients required re-repair. ConclusionIn this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.

Estudio comparativo de casos y controles concurrentes entre hernioplastia intraperitoneal laparoscópica y hernioplastia intraperitoneal abierta

IntroductionLaparoscopic incisional hernioplasty has demonstrated advantages in selected cases in terms of postoperative recuperation and complications, and it is comparable in recurrence to open incisional hernioplasty; however, this technique does not constitute the gold standard for incisional hernia repair. We recommend that laparoscopic incisional hernioplasty should be considered the gold standard technique to repair upper midline incisional hernias with rings of less than 10cm and without loss of domain. Patients and methodsProspective case-control study of patients operated for incisional hernia with laparoscopic and open techniques that were followed-up with previously validated instruments for the measurement of incisional hernia outcomes and postoperative complications, without direct intervention over the study population. ResultsOne-hundred twelve patients with M2 incisional hernia were included, of them 28 were submitted to laparoscopic surgery and 84 to open surgery. Both groups of patients were comparable in their general and hernia characteristics. Complications were more common in patients submitted to open surgery, being skin-related complications the most frequent. All patients complied with the two-year follow-up. During this period, outcomes were measured with the available instrument, evidencing the better outcomes of the laparoscopic technique. ConclusionsThe outcomes of laparoscopic incisional hernioplasty in selected upper midline hernias showed the superiority of this technique compared with the open technique.

TÉCNICA DE RIVES-STOPPA EN LAS EVENTRACIONES DE LA LÍNEA MEDIA: PRESCINDENCIA DE LA FIJACIÓN PERIMETRAL DE LA MALLA

Rives-Stoppa repair without mesh fixation for midline incisional hernias. Long term follow up Background: The Rives-Stoppa technique for midline incisional hernias places a Mersilene mesh in the retro rectal space, which is kept in place with transcutaneous sutures. Other forms of fixation have been pro posed. Aim: To assess the long term results of the surgical technique without fixation of the mesh. Material and Methods: An observational, descriptive, prospective study performed in 64 patients aged 26 to 85 years (48 women) consecutively operated between 1995 and 2002. The standard Rives-Stoppa technique was used, except for the usage of a Prolene mesh without fixation. Ambulation was started on the first postoperative day and patients were discharged after removal of drains. Results: Eighty percent of patients were obese, 25% had high blood pressure and 9% were diabetic. Patients were discharged at a median of four (range two-16) days after surgery. Four superficial infections, one case of thromboembolic disease, one case of prolonged ileus and two pulmonary infections were recorded as complications. A long term follow-up was carried out in 48 patients (75%). Five patients had small recurrences (10%), localized at the cephalic or caudal borders of the mesh, and six patients (13%) reported slight abdominal pain. In spite of recurrences, 97% of patients were satisfied or very satisfied with the treatment. Conclusions: These results are similar to those obtained using mesh fixation. Increasing distal and proximal mesh overlap should enhance these results.

Giant midline abdominal incisional herniae repair through combined retro-rectus mesh placement and components separation: experience from a single centre

Giant midline abdominal wall incisional herniae require repair/reconstruction to restore the structural and functional continuity of the anterior abdominal wall. We describe here our approach to these demanding cases through a combined retro-rectus mesh placement and components separation and their overall functional outcome. A retrospective analysis of a prospectively collected data was carried out and 28 patients who underwent giant (≥15cm) midline incisional hernia reconstruction were identified in a large district general hospital between 2007 and 2013 with a median follow-up of 34 (6-76)months. Demographic data of our series include age of 60 (median) (30-87)years with a M:F ratio of 12:16, length of symptomatic hernia 18 (median) (12-36)months, more than two previous laparotomies (15), bowel obstructive symptoms (7) and recurrent herniation (7). BMI recorded was 32 (median) (24-46) and ASA of II (median) (I-III). Co-morbidities included cardiac disease (6), diabetes (6), respiratory disease (4) and systemic immunocompromise (2). Operative and technical details showed operative duration to be 180 (median)min, cranio-caudal rectus sheath defect 21 (median)cm, transverse rectus sheath defect 15 (median)cm, cross-sectional area of fascial defect 300 (median)cm(2) and size of mesh 690 (median)cm(2). Seven (25%) developed short-term post operative complications: grade I seromata all resolving spontaneously (5); grade II superficial wound infections (2). Twenty-five (89%) were completely asymptomatic at 34 (median)months' follow-up; 2 (7%) reported mild pain, but not limiting any activity; 1 (4%) described pain occasionally limiting activity. There was no clinical recurrence with one patient developing global bulging. Our series is comparable to the literature in patient cohort demographics, co-morbidity and risk factor profile; however, we demonstrate an excellent intermediate term outcome with no clinical recurrence and an improvement in quality of life, through their ability to perform normal day to day activities.

Study of the outcome of modified shoelace repair for midline incisional hernia

To study the efficacy and short-term sequelae of modified shoelace repair for midline incisional hernias. A prospective non-randomized study of 30 cases of midline incisional hernias was carried out at a public hospital from May 2009 to Oct 2012. Patients underwent modified shoelace repair which comprises reconstruction of linea alba along with the use of polypropylene mesh to reinforce the facial layer. A proforma was maintained for each patient documenting patient details, nature of previous surgery and complications if any, postoperative course, and complications postincisional hernia repair. Thirty patients underwent this repair with no complications and no recurrence for minimum follow-up period of 12 months. Our technique is a simple extra-peritoneal procedure with no extensive tissue dissection and avoids the potential complications of bowel injury and adhesions with the mesh. The principle involved is that during straining, the recti shorten by tonic contraction and approximate toward the midline. An incisional hernia weakens the midline and causes the recti to move laterally with contraction as medial pull is lost. By reforming a strong new linea alba, there is restoration of medial pull on recti. This is further buttressed by the mesh. Modified shoelace repair is a simple and safe extra-peritoneal procedure and can be used for all midline incisional hernias.

Review of stoma site and midline incisional hernias after stoma reversal

BackgroundThe incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias. MethodsA systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done. ResultsSixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%–33.9%) and for midline incisional hernias was 44.1% (range 8.7%–58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. ConclusionStoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.

The Efficacy of Different Modalities Used In the Repair Of Incisional Hernias

Introduction: Incisional hernia is a serious surgical problem and has been reported to occur in 2 to 11 per cent of laparatomy incisions and remain a frequent and serious complication of abdominal surgery. Repair of large abdominal incisional hernias is a difficult surgical problem with recurrence being a common outcome. Major complications which can occur in repair of large incisional hernias include mesh infection and enterocutaneous fistula. The Aim Of The Study: is to evaluate and compare the efficacy of using Primary suture repair and On-lay mesh implantation in the repair of midline incisional hernias. Patient And Methods: A prospective study done during the period from January 2010 to January 2012 at AlKadhmyia Teaching Hospital in Baghdad. The patients’ full data regarding history of risk factors and abdominal surgical history were recorded. Among 76 patients with midline incisional hernia enrolled in this study, 41 patients of them were assigned to On-lay mesh repair and 35 patients to Primary suture repair. These patients were evaluated for 12 months after surgery either by outpatients’ clinic visits or phone. Results: The overall recurrence rate was seen in 12 patients (15.8%). It was seen in 9 patients (25.7%) of those who underwent Primary suture repair, while in 3 patients (7.3%) of those with On-lay mesh repair. In 75% of patients who developed recurrence, the recurrence occurred after 6 months of Incisional hernia repair. Conclusion: Prosthetic hernia repair gives acceptable recurrence rates and have a good results in comparison to suture repair. The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high risk patients.

Reconstruction of meshed linea alba and paramedican continuous suturing of mesh - a new approach in incisional hernia repair

Background: Irrespective of modern suturing technique of closure of abdominal wall, POIH(post-Op incisional hernia) is frequent complication of abdominal surgery, Repair of POIH with mesh has improved result & it has also reduced recurrence. Aims: To observe and scrutinize the technique in the form of simplicity, post-Op complication and anatomical reconstruction. Material &Methods: Patients having lower midline incisional hernia were operated upon by present technique of incisional hernia repair by reconstruction of meshed lineaalba were selected for the study. Patients were observed in Pre Op and Post-Op period & when they attend out-patient clinics. Data was collected in prescribed format& statistically analyzed to draw the conclusion. Result: In our study of 20 patients, 95% of females (n= 19) outnumbered 5% males (n=1). The highest incidence was in the 5th& 6th decade of life. No patients were found having major wound infection, seroma formation, or recurrence of hernia. 20 patients (100%) attended our follow up which ranged from 3 months to 6 months. 15 patients (75%) attended the OPD personally for follow up. Remaining 5 patients (25%) were questioned over the telephone and their response recorded. The average hospital stay recorded was 5-6 days. No recurrence was encountered in the follow up group. Conclusion: This technique of Reconstruction of meshed lineaalba was found to be technically simple, leading to least post op complications and attaining its goal of curing the lower abdominal incisional hernia.

Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up

Totally Laparoscopic Abdominal Wall Reconstruction (TLAWR) combines the laparoscopic component separation and the laparoscopic ventral hernia repair, with the purpose of further increasing the benefits of a minimally invasive procedure. However, neither the patient selection criteria nor the long-term results of this technique have been reported. Our objective is to discuss our experience with five patients who received a TLAWR. All patients with a midline incisional hernia who underwent a TLAWR from September 2008 to October 2009 were retrospectively reviewed for early and late postoperative complications. A total of five patients underwent the procedure, with a mean age of 48.6±7.9years. The mean length of stay was 9.2±5.4days, and follow-up was 12.3±6.8months. The mean defect size was 175.8±56.2cm(2). There were no early or late wound complications. Two patients had an early respiratory complication, and one patient developed a port site hernia and small bowel obstruction early after procedure, which required a re-operation. Three patients (60%) experienced a recurrence. Possible risk factors for recurrence include previous failed hernia repair, loss of domain, large hernias and close proximity to bony structures. Although TLAWR is feasible and improves wound complications, it may be associated with higher recurrence. Appropriate patient selection is imperative in order for the patient to benefit from this technique.

Multilayer Myofascial-Mesh Repair for Giant Midline Incisional Hernias: A Novel Advantageous Combination of Old and New Techniques

BackgroundThe components separation technique has been proposed as the best solution when facing large abdominal wall defects. In counterpart, this sometimes comes at the price of high rates of wound complications and recurrence. Moreover, the components separation method alone seems insufficient for huge defects, in which it is impossible to reapproximate the rectus muscles without tension. For these cases, we illustrate a novel operation using a modified components separation technique. MethodsTwenty-eight patients with giant midline incisional hernias were treated with a combination of the components separation (bilateral sliding rectus abdominis advancement flaps), an autologous multilayer repair, and a retromuscular mesh reinforcement. ResultsTwenty-four (85 %) patients have been analyzed. Transverse defect size ranged from 15 to 25 cm (average, 18.8 cm). Wound complications occurred in nine (37 %) cases; three of them required drainage of a subcutaneous abscess. After a mean follow-up of 22 (range, 12–48) months, one (4 %) recurrence was identified. ConclusionsMultilayer myofascial-mesh repair was associated with a low recurrence rate, and wound complications were managed without issues. This approach is a reliable technique for most surgeons and may constitute a new part of the armamentarium for the repair of challenging defects.

Parastomal hernias successfully repaired using a modified components separation method: two case reports

IntroductionParastomal hernia is a frequent complication after enterostomy formation. A repair using prosthetic mesh by way of a laparoscopic or open transabdominal approach is usually recommended, however, other procedures may be done if the repair is to be performed in a contaminated environment or when the abdominal cavity of the patient is difficult to enter due to postsurgical dense adhesion. The components separation method, which was introduced for non-transabdominal and non-prosthetic ventral hernia repair, solves such problems.Case presentationCase 1. A 79-year-old Japanese woman who underwent total cystectomy with ileal conduit for bladder cancer presented with a parastomal hernia, which was repaired using a keyhole technique. Simultaneously, an incisional hernia in the midline was repaired with a prosthetic mesh. One year after her hernia surgery, a recurrence occurred lateral to the stoma, but it was believed to be difficult to enter the peritoneal cavity because of the wide placement of mesh. Therefore, surgery using the components separation method was performed.Case 2. A 72-year-old Japanese man underwent an abdominoperineal resection for rectal cancer. At 5 and 12 months after his operation, a perineal hernia and an incisional hernia in the midline were repaired with prosthesis using a transabdominal approach, respectively. Three years after his rectal surgery, a parastomal hernia developed lateral to the stoma. For the same reason as case 1, surgery using the components separation method was performed. No recurrence was observed in either case as of 40 and 8 months after the last repair, respectively.ConclusionThe components separation method is a novel and effective technique for parastomal hernia repair, especially in cases following abdominal polysurgery or midline incisional hernia repairs using large pieces of mesh. To the best of our knowledge, this is the first report in English on the application of the components separation method for parastomal hernia repair.

Short-term Outcomes for Open and Laparoscopic Midline Incisional Hernia Repair

: The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications. : Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons. : Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks. : Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213). : Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537).

Eventraciones de la línea media: Técnica de Rives-Stoppa sin fijación de la malla. Resultados a largo plazo

IntroductionThe Rives-Stoppa technique for midline incisional hernias places a piece of mesh in the retro-rectal or in the preperitoneal space kept in place with transparietal transcutaneous perimetral sutures. In our study we want to show that allowing the fixation to take place by the so called «apposition sutures»’, the outcomes are similar to those obtained by suture fixation. Patients and methodsThe present observational, descriptive and prospective study was performed between 1995 and 2002 in midline incisional hernias with a defect width between 4 and 15cm. The Rives-Stoppa technique was realized following the technique recommended by the authors with the exception that Prolene® mesh was used and that no suture fixation was done. Ambulation was started the first postoperative day and patients were discharged after removal of the drains. Patients were controlled the 7th and 30th day after surgery. The longterm follow-up took place 10.8 (8–13) years after the intervention. ResultsThe present study was performed in 48 women and 16 men with a middle age of 58.8 ± 13.6. Obesity was present in 80.2%. The time of hospitalization averaged 2.8 (1–13) days. Six patients developed a superficial infection. The longterm follow-up showed 5 recurrences (9.6%) and 6 cases of light chronic abdominal pain. In spite of this, 97% of the patients were satisfied or very satisfied with the treatment. ConclusionOur results are similar with other studies with different mesh fixation techniques.

Extraction site location and incisional hernias after laparoscopic colorectal surgery: should we be avoiding the midline?

BackgroundLaparoscopic colorectal procedures require specimen extraction. It is unclear whether extraction site affects the incidence of incisional hernia (IH). MethodsPatients undergoing laparoscopic colectomy over a 6-year period were identified. Outcomes were compared between patients to evaluate the incidence of hernia. ResultsAmong 480 laparoscopic colorectal procedures, extraction sites were midline (n = 305), muscle splitting (n = 128), Pfannenstiel (n = 26), and ostomy (n = 21). Average follow-up was 3.5 years. Age, gender, diagnosis, extraction incision length, and hospital stay were similar. The mean body mass index for all patients was 28 kg/m2 and for those with IHs was 31 kg/m2 (P = .008). The overall IH rate was 7%. Midline IHs accounted for 84% of all hernias, occurring in 8.9% of midline extractions (P < .05 vs nonmidline extractions). Hernia rates for muscle-splitting, Pfannenstiel, and ostomy site extractions were 2.3%, 3.8%, and 4.8%, respectively. ConclusionsAlthough midline hernia rates were lower than traditionally reported with open surgery, midline extraction sites have a higher chance of IH than nonmidline sites.