Technique For Incisional Hernia Repair Research Articles

What are the trends in incisional hernia repair? Real-world data over 10years from the Herniamed registry.

There is an increasingly controversial debate about the best possible incisional hernia repair technique. Despite the good outcomes of laparoscopic IPOM, concerns about the intraperitoneal mesh placement and its potential intraabdominal complications have risen. Against that background, this paper now analyzes changes and trends in incisional hernia repair techniques in the recent decade. Between 2010 and 2019 a total of 61,627 patients with primary elective incisional hernia repair were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves to visualize trends. The explorative Fisher's exact test was used for statistical calculation of significant differences. Since the number of cases entered into the Herniamed Registry for the years 2010-2012 was still relatively small, the years 2013 and 2019 were compared for statistical analysis. In the analyzed time period, the proportion of incisional hernias repaired in open suture technique remained unchanged at about 10%. The proportion of laparoscopic IPOM repairs decreased significantly from 33.8% in 2013 to 21.0% (p < 0.001) in 2019. Conversely, the proportion of open sublay repairs increased significantly from 32.1% in 2013 to 41.4% (p < 0.001) in 2019. Starting in 2015, there has also been the introduction and increasing use (4.5% in 2013 vs. 10.0% in 2019; p < 0.001) of new minimally-invasive techniques with placement of a mesh into the sublay/retromuscular/preperitoneal abdominal wall layer (E/MILOS, eTEP, preperitoneal mesh technique). Analysis of data from the Herniamed Registry shows a significant trend to the disadvantage of the laparoscopic IPOM and to the advantage of the open sublay operation and the new minimally-invasive techniques (E/MILOS, eTEP, preperitoneal mesh technique). Despite all the recommendations in the guidelines, 10% of incisional hernias continue to be treated by means of a suture technique.

Analysis of 4,015 recurrent incisional hernia repairs from the Herniamed registry: risk factors and outcomes.

The proportion of recurrences in the total collective of all incisional hernias has been reported to be around 25%. In the European Hernia Society (EHS) classification, recurrent incisional hernias are assigned to a unique prognostic group and considered as complex abdominal wall hernias. Surgical repairs are characterized by dense adhesions, flawed anatomical planes caused by previous dissection or mesh use, and device-related complications. To date, only relatively small case series have been published focusing on outcomes following recurrent incisional hernia repair. This cohort study now analyzes the outcome of recurrent incisional hernia repair assessing potential risk factors based on data from the Herniamed registry. Special attention is paid to the technique used during the primary incisional hernia repair, since laparoscopic IPOM was recently deemed to cause more complications during subsequent repairs. In the multicenter Internet-based Herniamed registry, patients with recurrent incisional hernia repair between September 2009 and January 2018 were enrolled. In a confirmatory multivariable analysis, factors potentially associated with the outcome parameters (intraoperative, postoperative and general complications,complication-related reoperations, re-recurrences, pain at rest and on exertion, and chronic pain requiring treatment at one-year follow-up) were evaluated. In total, 4015 patients from 712 participating hospitals were included. Postoperative complications and complication-related reoperations were significantly associated with larger recurrent hernia defect size, open recurrent incisional hernia repair and the use of larger meshes. General complications were more frequent in female sex patients and when larger meshes were used. Higher re-recurrence rate was observed with lateral defect localization, present risk factors, and time interval ≤ 1year between primary and recurrent incisional hernia repair. Pain rates at 1-year follow-up were unfavorably related with pre-existing preoperative pain, female sex, lateral defect localization, larger mesh, presence of risk factors, and postoperative complications. As regards the primary incisional hernia repair technique, laparoscopic IPOM was found to show no effect versus open mesh techniques on the subsequent recurrence repair, despite a trend toward higher rates of complication-related reoperations. The outcomes of recurrent incisional hernia repair were significantly associated with potential influencing factors, which are very similar to the factors seen in primary incisional hernia repair. The impact of the primary incisional hernia repair technique, namely laparoscopic IPOM versus open mesh techniques, on the outcome of recurrent incisional hernia repair seems less pronounced than anticipated.

What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia.Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications.Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes.Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.

Evaluation of retro muscular mesh repair technique for treatment of ventral hernia

Ventral hernias commonly encountered in surgical practice account for 15-20% of all abdominal wall hernias. Results of tissue repair have been disappointing. The optimal approach for abdominal incisional hernias is still under discussion. The aim of the study was to evaluate the retro muscular mesh repair technique in the treatment of ventral hernia as one of the standard techniques for treatment of such cases. This prospective study on 50 consecutive patients was performed from July 2016 to July 2017. Patients were prepared to be operated by the retro muscular mesh repair technique. All patients were evaluated with respect to operative time and postoperative complications. Results were documented and statistically analysed. In this study on 50 patients, there were 30 female patients (60%) and 20 male patients (40%). The age of the studied patients ranged between 26 and 65 years with mean age of 49.8 years. The mean operative time was 88.5±15.3 min. The mean period of drainage was 2.3±1.3 days. Seroma was encountered in one case only 2%. No recurrence was reported in the studied patients during the period of follow-up (12months). On the basis of this study, we conclude that retro muscular (sublay) mesh repair is the ideal technique for incisional hernia repair.

Revisiting the Anterior Rectus Sheath Repair for Incisional Hernia: A 10‐Year Experience

Surgeons continue to seek an incisional hernia repair technique which minimizes cost and morbidity while maximizing durability. We present a single surgeon's experience with a technique described by N.L. Browse and J.P. Chevrel in 1979. The Chevrel/Browse repair consists of a bilateral anterior rectus sheath release, hernia sac imbrication, bilateral rectus complex medialization, and repair reinforcement with an anterior prosthetic mesh. Data were collected on all patients who underwent herniorrhaphy between April 2003 and April 2013. A total of 123 patients underwent repair. These had undergone an average of 2.6 prior abdominal operations and 0.7 prior hernia repairs; the average defect size was 64.77±86.79cm2. Twelve patients had lateral components release in addition to release of the anterior rectus sheath to achieve midline re-approximation with minimal tension. Synthetic mesh was used in 81% of repairs and biologic mesh in 19%. The most common complications were seroma formation (21%) and incisional skin breakdown (30%); no deaths occurred. The overall recurrence rate was 5.1%, and 7% for the group which had follow-up greater than 36months. Use of biologic mesh increased the rate of seroma formation compared with synthetic mesh (50 vs. 14%, p<0.001), but did not increase the rate of wound breakdown (36.3 vs. 29.6%, p=0.72). This case series describes the utilization of anterior rectus sheath release and mesh placement which is anterior to the rectus muscle. Hernia recurrence and intra-abdominal complications are observed to be uncommon after repair using this technique. Future prospective randomized studies are warranted.

Reconstruction of the Abdominal Wall in Anatomical Plans. Pre- and Postoperative Keys in Repairing "Cold" Incisional Hernias.

Background and aimsThe clinical results of the vertical “vest-over-pants” Mayo repair were evaluated, and the risk factors for incisional hernia recurrence were studied. The purpose of this study is to point out the importance of reducing pre and post operative risk factors in the incisional hernia repair process in order to achieve a physiologically normal abdominal wall.MethodsTwenty patients diagnosed with incisional hernia underwent an abdominal reconstruction procedure using the Mayo (Paletot) technique at Bichat Claude Bernard Hospital between 2005 and 2015. All procedures were performed by a single surgeon and all patients were pre-operatively prepared, identifying all coexisting conditions and treating them accordingly before undergoing surgery.ResultsAll patients underwent at least one surgical operation before the hernia repair procedure and a quarter had experienced at least three, prior to this one. Nine patients had a body mass index of >30 kg/m2. Additional risk factors and comorbidities included obesity in 45%, diabetes mellitus in 10%, smoking in 55%, and high blood pressure in 40%. Hernia defect width was from 3 cm (25% F) to 15 cm (5% M) of which nine patients (45%) had a 10 cm defect. Most of the patients had an average hospitalization of 7 days. The patients were carefully monitored and were called on periodic consultations after 3, 6, and 12 months from the moment of the procedure. Patient feedback regarding hernia recurrence and complaints about the scar were noted. Physical examination is essential in determining the hernia recurrence therefore the scar was examined for any abnormalities that may have occurred, which was defined as any palpable or detected fascial defect located within seven centimeters of the hernia repair. Post-operative complications: seroma formation, wound hematoma, superficial and deep wound infection, recurrences and chronic pain were followed and no complications were registered during the follow-up period.ConclusionsReducing the risk factors to a minimum prior to surgery will increase the success of the incisional hernia repair and generate a positive impact on the patient’s quality of life. The lofty goal of significant weight loss prior to elective hernia has shown to be the key factor in using the Mayo technique for incisional hernia repair. This study demonstrates that the Mayo repair technique is a suitable and trustworthy alternative for repairing incisional hernias with very good results. It’s costs are minimal and it can be easily reproduced, even by less experienced surgeons.

Outcome of tension free repair of incisional hernia

Background: The surgical treatment ofincisional hernia has changed rapidly during the last decade with the increasing use of mesh technique and the introduction oflaparoscopy. However, many questions concerning mesh type, mesh positioning, fixation method and operation type still remain unanswered. Methods: The study includes 100 cases of anterior abdominal wall hernias, including incisional hernia (cicatricial or paralytic types). The idea of the tension free repair of anterior abdominal wall hernia depends on repair of the defect by double layer onlay polypropylene mesh the deeper mesh is fixed to the free edge of the defect by polypropylene (No.1). The mean operative time was 2 hours (ranging between 1.5- 4 hours). Follow up of the patients was performed every 3 month with maximum follow up of two years and a minimum of six months. Results: The early postoperative course was uneventful in 96 patients (96%). Four patients presented with wound infection, two patients presented with superficial infection, the other two patients presented with deep infection and exposed mesh. The follow up revealed 8 cases of recurrent hernia (8%), two ofthese cases were associated with obesity, and one case was associated with bronchial asthma. Conclusion: In our study we modified the onlay technique for incisional hernia repair by using double layer onlay polypropylene mesh the deeper mesh is fixed to the free edge of the external oblique muscle, this modification insured a tension free repair of the hernia, the technique is universal and can be applied in both scar and paralytic insicional hernia.

Interposition of the omentum and/or the peritoneum in the emergency repair of large ventral hernias with polypropylene mesh

BackgroundVentral and incisional hernias are common surgical problems and their repairs are among the common surgeries done by a general surgeon. Repair of a large ventral hernia is still associated with high postoperative morbidity and recurrence rates. No single approach to ventral hernia repair will be the best choice for all patients. Large ventral hernias are often better approached with open surgery but may still be problematic when the defect is too wide for primary fascial closure to be achieved, as this leaves mesh exposed, bridging the gap. Techniques for incisional hernia repair have evolved over many years, and the use of mesh has reduced recurrence rates dramatically. The use of polypropylene mesh is reported to be associated with long-term complications such as severe adhesions and enterocutaneous fistula, which occur more commonly if the mesh is applied intraperitoneally with direct contact of the serosal surface of the intestine. Composite meshes containing expanded polytetrafluoroethylene (ePTFE) have been used recently; their major drawbacks lie in their high cost, inferior handling characteristics, and poor incorporation into the tissues. Although several studies have clearly demonstrated the safety and efficacy of prosthetic mesh repair in the emergency management of the incarcerated and/or strangulated inguinal and ventral hernias, however, surgeons remained reluctant to use prosthetics in such settings. PurposeThe aim of this work was to evaluate the effectiveness and safety of placing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in the emergency repair of large ventral hernias using on-lay polypropylene mesh whenever complete tension-free closure of the abdominal wall was impossible. Patients and methodsThis study was carried out on all patients with large ventral hernia presented to the Gastrointestinal Surgery Unit, Main Alexandria University Hospital in an emergency situation during the period from October 2005 till October 2012. All patients were treated by placing the omentum and/or the peritoneum of the hernia sac between the viscera and the mesh whenever complete tension-free closure of the abdominal wall was impossible. Some patients necessitated removal of previous meshes and resection-anastomosis of the non-viable bowel prior to mesh repair. Those who underwent complete closure of the abdominal wall without tension prior to mesh repair were excluded from the study as there was no need for interposition of the omentum and/or peritoneum. All patients' data, surgical procedures, complications and follow-up were collected, reviewed and analyzed. After approval of local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were informed well about the operative procedure and use of prosthetic mesh and an informed written consent was obtained from every patient before carrying the procedure. ResultsBetween October 2005 and October 2012; 105 patients (13 males and 92 females) with incarcerated and/or strangulated large ventral hernias were operated upon in the Gastrointestinal Surgery Unit, Main Alexandria University Hospital using an onlay polypropylene mesh. Their age ranged from 37 to 83 years with a mean of 59.3 + 11.7 years. The hernia was para-umbilical in 5 patients (4.8%), incisional in 22 patients (21%) and recurrent in 78 patients (74.3%). The recurrent hernias were recurrent para-umbilical hernias in 56 patients and recurrent incisional hernias in 22 patients. Resection anastomosis of non-viable, devitalized or injured small intestine during removal of adherent previous meshes was performed in 19 patients (18%). Hospital stay ranged from 2 to 13 days with a mean of 3.57 + 1.6 days. There was one perioperative mortality. Complications were encountered in 28 patients (26.7%) and included wound infection with delayed wound healing in 6 patients, seroma formation in 12 patients, chest infection in 8 patients and deep vein thrombosis in 2 patients. Follow-up duration ranged from 13 to 80 months with a mean of 46.8 + 20.3 months. ConclusionPlacing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in repair of incarcerated and/or strangulated large ventral hernia using on-lay polypropylene mesh is cost-effective and safe even with resection anastomosis of small intestine.

Evaluation of retromuscular mesh repair technique for treatment of ventral incisional hernia

Introduction Incisional hernia is a common surgical condition with a reported incidence of 2-11% following all laparotomies. Results of tissue repair have been disappointing. The optimal approach for abdominal incisional hernias is still under discussion. Objectives The aim of the study was to evaluate the retromuscular mesh repair technique in the treatment of ventral incisional hernia as one of the standard techniques for treatment of such cases. Materials and methods This prospective study on 52 consecutive patients was performed from July 2010 to February 2013. Patients were prepared to be operated by the retromuscular mesh repair technique. All patients were evaluated with respect to operative time and postoperative complications. Results were documented and statistically analyzed. Results In this study on 52 patients, there were 37 female patients (71.2%) and 15 male patients (28.8%). The age of the studied patients ranged between 20 and 61 years with mean age of 45.4 years. The mean operative time was 84.88 ± 18.04 min. The mean period of drainage was 3.1 ± 0.9 days. Seroma was not encountered in any patient. No recurrence was reported in the studied patients during the period of follow-up (12-30 months). Conclusion On the basis of this study, we conclude that retromuscular (sublay) mesh repair is the ideal technique for incisional hernia repair.

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.

Ideal technique of incisional hernia repair: the quest continues.

We have read with interest the article “A comparative analysis on various techniques of incisional hernia repair—experience from a tertiary care teaching hospital in South India” by Kumar et al. [1]. We would like to complement the authors for managing such a large number of patients within a time span of 2 years and following them over a period of 5 years. We believe that certain aspects of this article need clarification: preperitoneal mesh placement was coined “onlay meshplasty” in the introduction but “underlay repair” in the comments section. Traditionally, an onlay repair denotes the site of implantation of the mesh on the anterior rectus sheath, inlay repair implies fixation of the mesh to the aponeurotic edges of the rectus sheath, and underlay or sublay repair means the mesh is placed in the retrorectus and preperitoneal space [2]. The patients were subjected to different techniques of repair irrespective of the size of hernia and followed up for 5 years as per the prospective study protocol; however, the analysis section mentioned that anatomical repair was attempted in patients with size of defect less than 5 cm, while patients were followed up for a variable period of 2–24 months. The authors had observed statistically significant difference in the intensity of postoperative pain and the rate of recurrence following hernia repair, but they were silent about the type of statistical test used and the level of significance considered for comparing the parameters. Chi-square and Fisher exact tests are the commonly used tests for proportions involving qualitative variables. The study had recorded that postoperative pain was more (VAS score >5) with underlay repair than onlay repair (p < 0.005) and anatomical repair (p < 0.001). Applying Fisher exact test with a p value of <0.05 taken as significant difference to the same set of observations revealed significant increase in pain intensity in underlay repair when compared to anatomical repair (p = 0.002), but not in relation to onlay repair (p = 0.052). Similarly in respect to the rate of recurrence following anatomical (6/21) and mesh repair (5/48), the difference was not found to be statistically significant with a p value of 0.077 on Fisher exact test. This casts a doubt about the authors’ proposition for repair of all incisional hernias with mesh reinforcement on the basis of their study. Follow-up loss of ≥20 % greatly reduces the validity of the observed results in a prospective study [3]. Loss to follow-up in this study stood at 21/90 (23.3 %) patients, and the recurrence rate was calculated in the remaining 69 patients. Since a total of 11/69 patients experienced hernia recurrence, the overall recurrence rate was 15.94 % and not 12 % as the authors had claimed. Lastly, the ongoing quest for the ideal technique of incisional hernia repair in Indian scenario is still continuing. The breakthrough can only be achieved by a high quality randomized controlled trial having a large sample size from this part of the world.

Tollerability of incisional hernia repair in local anesthesia for old patients in a day surgery setting

Background Nowadays the gold standard of the incisional hernia surgical treatment seems to be the prosthetic repair. In the last 15 years many Authors published about the advantages of the laparoscopic treatment in front of the Open one, even if this issue till today remains controversial [1]. Anyway our group from 18 years is engaged on a clinical application of a third way of incisional hernias repair with an open prosthetic technique under local anesthesia which feasability was already demonstrated [2]. Other published experiences already exists [2]. At the beginninig of our experience we started with small incisional hernias [3]; over the time we submitted to procedure even incisional hernias with orifice’s diameter till 10 cm. Intraoperative sufferance of patients is questioned. The aim of this work is to show the patient’s tolerance to this open preperitoneal mesh technique of incisional hernia repair in local anesthesia in the elderly.

The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese

BackgroundBecause of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure. MethodsWe performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m2. The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up. ResultsMean patient age was 53 years (range 32–75 yr) with mean BMI of 46 kg/m2 (range 41–60 kg/m2). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively. ConclusionThe PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.

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).

Rhabdomyolysis: An unusual complication following endoscopic component separation hernia repair.

Separation of components technique for incisional hernia repair is increasingly utilized as a strategy for hernia repair in both the obese and those with loss of abdominal domain. Endoscopic component separation technique [ECST] is increasingly performed to minimize wound complications associated with the open procedure. We present a case of a patient who developed acute renal failure related to rhabdomyolysis following ECST. A 62-year-old morbidly obese female with BMI of 46 underwent ECST hernia repair for a large midline hernia with loss of domain. Postoperatively, she was found to be oliguric with a dark brown colored urine, elevated serum creatinine and blood urea nitrogen, and increased urine myoglobin levels. She recovered with aggressive hydration and urine alkalinization. We present this unique complication and review the literature.

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.

Rives-Stoppa incisional hernia repair combined with laparoscopic separation of abdominal wall components: a novel approach to complex abdominal wall closure

The Rives-Stoppa incisional hernia repair is the gold standard for mesh repair of complex incisional hernias. The risk of infection can be reduced if fascia is closed over the prosthetic mesh. Fascial closure in large defects may require extensive dissection and can result in devascularization of the overlying skin and denervation of the abdominal wall musculature. Laparoscopic components separation minimizes these risks while facilitating anterior fascial closure. The combined technique of Rives-Stoppa repair augmented by laparoscopic separation of abdominal wall components has not previously been reported. We retrospectively reviewed our initial experience with this combined technique for incisional hernia repair. A Rives-Stoppa incisional hernia repair is performed with mesh placed in the retromuscular position. If the anterior fascia cannot be closed, a laparoscopic separation of abdominal wall components is performed to facilitate fascial closure without creation of skin flaps. Six patients were identified. Three patients developed hernias following laparotomy from severe injuries sustained during combat. The other patients included hernia after esophagectomy, retroperitoneal liposarcoma resection, and complicated diverticulitis. Average defect size was 270 cm(2). Complete primary fascial closure anterior to the mesh was achieved in 66% of the patients. No mortalities occurred and at short term follow-up no incisional hernia recurrences have developed. Early post operative complications included a superficial skin infection not involving mesh and a recurrent enterocutaneous fistula. The authors conclude that Rives-Stoppa repair augmented by laparoscopic components separation is an innovative method for reconstruction of complex abdominal wall defects. Laparoscopic components separation allows fascial closure to be achieved anterior to the mesh in large incisional hernias, which may reduce wound infection rates.

The da Silva method of incisional hernia repair.

A technique of incisional hernia repair originally devised by da Silva is described. The operation was performed on 30 patients and no recurrence was found in the 27 cases examined 1 to 4.5 (mean 2.5) years later.

Efeito do ultra-som na prevenção da hérnia incisional mediana em ratos

OBJETIVO: Investigar se o ultra-som é capaz de evitar o aparecimento da hérnia incisional (HI), uma vez que o seu tratamento ainda é um problema não resolvido. MÉTODO: Induziu-se a HI, por secção da linha alba, em 20 ratos Wistar, distribuídos em dois grupos: um recebeu a aplicação do ultra-som, na área operada, por 14 dias e o outro por 28 dias, cada qual com seu subgrupo controle (não tratado). Utilizou-se aparelho com cabeçote reduzido, modo pulsado (1:5), freqüência de 3,0MHz e intensidade de 0,5W/cm², durante 5min/dia, iniciando-se as aplicações no primeiro dia pós-operatório. Ao final, mediu-se o diâmetro transverso do anel herniário ou da largura da cicatriz na linha alba, definindo-se a HI quando esses valores ultrapassassem 2mm. A densidade de vasos sangüíneos, de fibroblastos e de fibras colágenas, nessas estruturas, foi estudada à microscopia óptica. As médias e o erro padrão foram submetidos à análise de variância (ANOVA) e ao teste de comparação múltipla de Tukey-Kramer. RESULTADOS: Dos animais tratados com o ultra-som, 60% não desenvolveram HI e, nos restantes, o anel herniário foi menor do que os não tratados (p&lt;0,0001). A densidade de vasos sangüíneos (p=0,0031), de fibroblastos (p&lt;0,0001) e de fibras colágenas (p=0,0015) também foi maior, em relação aos controles. Não houve diferença significante nesses parâmetros, comparando-se os dois períodos de tratamento. CONCLUSÃO: O ultra-som evitou o aparecimento da HI ou reduziu o seu tamanho, quando aplicado por 14 dias pós-operatórios, nas condições deste experimento.

Simplified technique for incisional hernia repair with mesh prosthesis.

This paper describes a simplified technique for the repair of incisional hernias. The previous scar is resected, and the peritoneal sac is carefully dissected until it is completely exposed. The sac is opened to liberate structures adherent to the sac or to the area immediately surrounding the defect. The peritoneum is closed and invaginated to form a sac bed underlying the entire extent of the defect, and the mesh is laid on this sac bed. The mesh is then fixed with "U" stitches, reinforcing these by inserting a second line from the edge of the defect to the mesh. Suture material used is polypropylene 1/0 or 2/0. This procedure has been carried out on 15 patients, and after 1 year of follow-up, there has been no recurrence of the hernia. Operating time was reduced, and the surgical technique was found to be easier. Placing a mesh prosthesis inside the hernia sac and fixing it to the abdominal wall with two lines of suturing simplifies the repair procedure, reduces operating time, and is effective in the repair of all incisional hernias. A study is required to compare this outcome with the different mesh repair techniques.