Incisional Hernia Surgery Research Articles

The management of incisional hernia.

Many thousand laparotomy incisions are created each year and the failure rate for closure of these abdominal wounds is between 10-15%, creating a large problem of incisional hernia. In the past many of these hernias have been neglected and treated with abdominal trusses or inadequately managed with high failure rates. The introduction of mesh has not had a significant impact because surgeons are not aware of modern effective techniques which may be used to reconstruct defects of the abdominal wall. This review will cover recent advances in incisional hernia surgery which affect the general surgeon, and also briefly review advanced techniques employed by specialist surgeons in anterior abdominal wall surgery.

Incisional hernia repair in Sweden 2002

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

Aktuelle Aspekte der Hernienchirurgie

In the last 10 years in Germany we have seen a lot of hernia repairs using mesh.Meta-analysis shows the advantages of using meshes in hernia surgery; recurrence rates in inguinal hernia surgery are less than 3% in studies. There is some discussion about minimally invasive surgery in Germany.In incisional hernia surgery there is no discussion about using meshes. The role of minimally invasive surgery has not yet been defined.

Antibiotic prophylaxis in incisional hernia repair using a prosthesis

Antibiotic prophylaxis in clean surgery with implantation of prosthetic material is widely accepted, although there are no studies on its use in abdominal incisional hernia repair. The objective was to evaluate antibiotic chemoprophylaxis in incisional herniorrhaphy with the implantation of prosthetic material. A prospective non-randomized study (1990-1998) was conducted to analyse 216 patients undergoing surgery for abdominal incisional hernia who required a prosthesis (polypropylene) in the reconstruction and who met the criteria for clean surgery. Risk factors were observed in 31.5%, the most frequent being diabetes and obesity. The incisional hernia was located mostly in the abdominal midline and in 64.4% measured over 10 cm. Antibiotic prophylaxis was administered in 140 patients (64.8%) via the systemic route, the antibiotics being first- or second-generation cephalosporins or amoxicillin-clavulanic acid. Surgical wound infection occurred in 39 patients (18.1%), 19 who had received antibiotic prophylaxis (13.6%) and 20 who had not (26.3%). In multivariate analysis using logistic regression, the variables with statistical significance for local septic infection were antibiotic prophylaxis and number of risk factors. We can conclude therefore that antibiotic chemoprophylaxis is useful in abdominal incisional herniorrhaphy surgery with implantation of prosthetic material for reducing local septic complications.

Classification and surgical treatment of incisional hernia. Results of an experts' meeting.

The treatment of incisional hernia (IH) is a current problem in modern surgery. Many important aspects of incisional hernia surgery are yet to be answered, especially the choice of surgical technique and its adaptation to the individual patient. The aim of this experts' meeting was to resolve some current questions in incisional hernia surgery and to organise an international hernia register. An international panel of ten experts met under the auspices of the European Hernia Society (GREPA) to investigate the classification and therapeutic alternatives for incisional hernia. Prior to the conference, all experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The information from this correspondence was used as a basis for panel discussion. The personal experiences of the participants and other aspects of individualised therapy were also considered. The expert panel suggested a new classification of incisional hernia based on localisation, size, recurrences and symptoms. All experts agreed that the fascia duplication and the fascia adaptation should only be used for small incisional hernias. Fascia duplication is of value only in the horizontal direction. The technical details and the pros and cons of each procedure were discussed for prosthetic implantation using onlay and sublay techniques and the technique of autodermal hernioplasty. The management of incisional hernia is currently not standardised. In order to answer relevant questions of incisional hernia surgery, an international hernia register should be established.

Surgical treatment of incisional hernias with marked loss of substance

The surgical approach for the treatment of abdominal incisional hernias is a difficult problem. Only the use of prosthetic materials can provide a solution, yet their use in case of abundant loss of peritoneum can involve complications due to direct contact between the mesh and the intestine. The use of prosthetic materials in reconstruction of the abdominal wall highlights two closely connected problems: the kind of mesh to be used and the best implant site The prosthesis should be positioned only in the pre-peritoneal space or in the retromuscular prefascial plane. We report our experience with a surgical technique in which the peritoneum is integrated with an absorbable prosthesis and the nonabsorbable prosthesis is positioned in the neo-preperitoneal plane. From January 1992 to January 2000 65 patients underwent surgery for large incisional hernias. The follow-up period ranged from 6 to 60 months. There were 15 (23.1%) early complications (seromas, hematomas and infections) and 2 (3.1%) late complications: a fistula between the skin and the prosthesis and a subacute infection of the abdominal wall. No recurrence was noted. In patients with abundant loss of substance there is no real pre-peritoneal space; therefore a new one must be created to restore the mechanical and functional structure of the peritoneum. The prosthetic Vicryl® mesh permits good tissue repair with almost no involvement of the intestinal loop. Follow-up studies confirm the efficacy of this method.

CONTINUOUS MONOFILAMENT POLYAMIDE (LOOP) SUTURE IN THE REPAIR OF RECURRENT AND COMPLICATED INCISIONAL HERNIA

Surgery for recurrent incisional hernia is followed by further recurrence in nearly half the patients. Majority of these failures are due to wound complications and factors which give rise to an increased strain on the suture line. In an effort to counter the risk factors, continuous monofilament nylon loop suture was used in the anatomical repair of 15 patients with recurrent and complicated incisional hernia. After a median follow up of 14 months only one patient (6.6%) developed a recurrence, despite selecting only poor-risk patients. This technique for anatomical repair of incisional hernia seems safe and dependable.

胸部食道癌に対する頸部上縦隔拡大リンパ節郭清の意義と問題点

Objective: This study compares outcomes following open and laparoscopic partial posterior fundoplication for gastroesophageal reflux disease concerning perioperative course, postoperative complications, symptomatic relief, recurrent disease, and the need for reinterventional surgery. Methods: A prospective randomized trial was performed. Pre- and postoperative testing included endoscopy, esophageal function testing, patient questionnaire, and clinical assessment. Patients were followed for three years. Materials: Ninety-three patients were randomized to open and 99 to laparoscopic surgery. Results: Complication rates were higher, and length of stay (LOS) [5 (3–36) vs 3 (1–12) days] and time off work [42 (12–76) vs 28 (0–108) days] was longer in the open group (p < 0.01). Early side effects and recurrences were more common (p < 0.05) in the laparoscopic group. One patient in the open group and 8 patients in the laparoscopic group required surgery for recurrent disease and 7 patients required surgery for incisional hernias after open surgery. Overall, at one and three years, there were no differences in patientassessed satisfactory outcome (93.5/93.5 vs 88.8/ 90.8%) or reflux control (p = 0.53) between the open and laparoscopic groups. Conclusions: The finding of fewer general complications, shorter length of stay and recovery, similar need for reoperations, and comparable 3-year outcomes, makes the laparoscopic approach the primary choice when considering surgical options for the treatment of gastroesophageal reflux disease (GERD).

Controlled succinylcholine infusion in a patient receiving echothiophate eye drops

A 69 year old man receiving echothiophate eye drops for glaucoma was given a controlled infusion of succinylcholine during elective surgery for incisional hernia. Neuromuscular blockade was assessed by the measurement of the force of contraction of the adductor pollicis muscle. Only 9.5 mg succinylcholine were required for tracheal intubation and 1.1 mg/min for maintenance. When the infusion was stopped, recovery of neuromuscular transmission was rapid and uneventful. Plasma cholinesterase activity was 62 per cent below normal, but the enzyme was qualitatively normal. Thus, muscle relaxation can be achieved safely with a succinylcholine infusion in patients with decreased plasma cholinesterase activity if neuromuscular function is closely monitored.