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REVIEW

The Royal College of Surgeons of England


Ann R Coll Surg Engl 2006; 88: 252260
doi 10.1308/003588406X106324

The management of incisional hernia


ANDREW KINGSNORTH

Department of Surgery, Derriford Hospital, Plymouth, UK


ABSTRACT

Many thousand laparotomy incisions are created each year and the failure rate for closure of these abdominal wounds is
between 1015%, 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 signif-
icant 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.

KEYWORDS
Incisional hernia Abdominal wall Repair
CORRESPONDENCE TO
Andrew Kingsnorth, Consultant Surgeon, Derriford Hospital and Professor of Surgery, Peninsula Medical School, Level 7, Derriford Hospital,
Plymouth PL6 8DH, UK
T: +44 (0)1752 763017; F: +44 (0)1752 763007; E: [email protected]

Medline (19802005) and Embase were searched using the tissue approximation with sutures and this topic will not be
search terms hernia and incisional alone and in combin- discussed further.5 Small incisional hernias with time
ation. Publications were selected mostly in the past 5 years, develop into larger incisional hernias due to the continuous
but did not exclude commonly reference and highly regarded presence of intra-abdominal hydrostatic pressure of 15 cm
older publications. The reference list of articles was also of water, diaphragmatic contractions occurring with
searched, identified by the search strategy and those selected respiration, increases in abdominal pressure occurring
that were relevant. Selected review articles and meta- with coughing and straining realising pressures of over
analyses were included because they provide comprehensive 80 cm of water and myofascial retraction of the lateral
overviews that may be beyond the scope of this article. muscles. As a result, the abdominal cavity contracts and the
right of domicile for the herniated visceral mass is lost.6
Due to several previous operations, many of these patients
Overview
have poor-quality abdominal wall musculature which,
The introduction of prosthetic mesh revolutionised the coupled with multiple co-morbid medical problems,
treatment of groin hernia but, to date, has had little impact present a surgical and anaesthetic challenge.
on the treatment of incisional hernia.1 The risk factors for Surgeons appear to have a reluctance to operate on inci-
the development of incisional hernia include obesity, sional hernias perhaps because of the poor general condi-
diabetes, emergency surgery, postoperative wound tion of the patients but perhaps also due to lack of knowl-
dehiscence, smoking and postoperative wound infection.2,3 edge of how to deal with the various defects occurring as a
The risks of repairing an incisional hernia which should be result of incisions of the anterior abdominal wall and the
explained to the patient when obtaining consent include operative techniques required. For instance, although it is
seroma formation, wound infection, injury to intra- estimated that 13% of laparotomy incisions fail in The
abdominal structures and recurrence.4 Major complications Netherlands, only 4% of patients undergoing a laparotomy
which can occur in repair of large incisional hernias will go through additional surgery to repair an incisional
include mesh infection and enterocutaneous fistula which hernia.7 Suture repair is likely to produce results twice as
may result in prolonged morbidity and require re-operation bad as mesh repair and the current techniques that surgeons
(Fig. 1). It is now accepted that only the smallest (less than are using to repair incisional hernias with prosthetic mesh
3 cm) incisional hernias should be repaired with primary continue to yield recurrence rates of greater than 20%.8

252 Ann R Coll Surg Engl 2006; 88: 252260


KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

expansion, vacuum-assisted closure devices, local and distant


muscle flaps, and free tissue transfer. This usually means that
the abdominal surgeon will be working in partnership with
plastic surgeons.13 Rohrich et al.13 have devised an algorithm
for this approach to abdominal wall reconstruction.
Dumainian and Denham14 have brought laparoscopic surgery
into this algorithm. These authors have stated that a transverse
size of 10 cm is the upper limit for the laparoscopic approach,
but some authors have pushed this limit to 15 cm.
Laparoscopic incisional hernia repair and the sliding
myofascial rectus flap (components separation technique) are
diametrically opposed solutions to the same clinical problem.
However, the Ramirez operation can successfully repair
hernias as large as 35 cm in transverse diameter achieving
abdominal wall closure and no subsequent abdominal
compartment syndrome. Which middle-sized hernias of
between 1015 cm in transverse diameter should be repaired
with the laparoscope is still open for debate. Those over 15 cm
in transverse dimension usually require an open supple-
mentary components separation operation. Absolute contra-
indications for the laparoscopic operation include patients
who have had a previous incisional hernia repair (due to the
usual dense adhesions encountered), those with loss of
domain (because the contents of the hernia sac cannot be
reduced), open wounds (insufflation is impossible) and where
additional gastrointestinal surgery is required.
Figure 1 Serious morbidity from attempted incisional hernia repair
showing recurrent hernia, enterocutaneous fistula, (short bowel
syndrome) and long-term TPN. Prevention and prophylaxis
Wound failure after abdominal wall closure is surgeon-
Where endoscopic access is a viable option for intra- dependent.15 Several meta-analyses have recently been
abdominal surgery, it should be used on the grounds that performed to reveal optimal techniques for closure of
laparoscopic access results in considerably fewer wound abdominal incisions. Hodgson and colleagues16 determined
hernias and postoperative episodes of small bowel obstruc- that lower recurrence rates occurred with the use of non-
tion.9 Collagen disorders such abdominal aortic aneurysm absorbable materials utilising a continuous suture. vant Riet
and Ehlers-Danlos syndrome greatly increase the risk of and colleagues17 revealed similar outcomes with continuous or
abdominal wall hernias.3,10 interrupted techniques and that a slowly absorbable suture
Because large areas of prosthetic mesh are utilised in the was as effective as a non-absorbable suture. Finally, Rucinski
repair of large incisional hernias, it is probably this area of sur- and colleagues18 concluded that a continuous mass (all layers)
gery that will benefit maximally from the development of bio- closure with absorbable monofilament suture material was
compatible meshes with near physiological functional proper- the optimal technique. Several authors have supplemented
ties that produce the lowest possible foreign body reaction and primary abdominal wall closure with prosthetic mesh to
be of the minimum necessary tensile strength.11 reduce the incidence of wound failure. After aortic aneurysm
repair and obesity surgery. the incidence of wound failure can
be reduced to nearly zero.19,20 Recent studies by Israelsson and
The management plan colleagues21 have demonstrated that the routine use of
Langer and colleagues,12 in a comparative, retrospective lightweight mesh when constructing a stoma should become
study of over 400 incisional hernia operations over a 25- routine practice.
year period, estimated that the most important prognostic
factor is the surgeons experience. For a surgical team to
Pre-operative preparation
offer a complete service for abdominal wall reconstruction,
the following techniques should be mastered: prosthetic Where an abdominal wall hernia is complex and clinical
materials, abdominal components separation, tissue assessment is considered to be insufficient (particularly in

Ann R Coll Surg Engl 2006; 88: 252260 253


KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

Figure 2 Incisional hernia with significant loss of domain.

multiply recurrent hernias with multiple defects), then


imaging with CT scanning can be particularly helpful.22,23
Occult defects are accurately delineated, the contents of the
sac defined and an estimate can be made of the percentage of
the abdominal contents that have lost domain. Significant loss
of domain, which may result in abdominal compartment
syndrome if the contents were to be reduced into the
remaining peritoneal cavity, is considered to be approxi-
mately 20% and such hernias are particularly difficult to Figure 3 Trophic ulcer in skin overlying long-standing hernia.

repair with complete closure of the abdominal wall


myofascial layers (Fig. 2). Morena24 and Mason25 described
pneumoperitoneum as a potential means of overcoming the open and laparoscopic techniques from a structured
problem of loss of domain by increasing the size of the Medline search. Only eight of these studies met inclusion
remaining peritoneal cavity prior to surgery. This technique, criteria for the study of the three main outcome measures
however, has not been widely adopted because of its peri-operative complications, operative time and length of
complexity and lack of efficacy. hospital stay. This resulted in an overall comparison of 390
The benefits of antibiotic prophylaxis in incisional hernia patients having open repair and 322 with laparoscopic
repair has not been put to the test of a randomised, controlled repair. Peri-operative complications and length of stay were
trial. However, Rios and colleagues,26 in a non-randomised reduced in the laparoscopic group. LeBlanc et al.,29 the first
study, detected a small diminution with antibiotic prophylaxis to describe laparoscopic incisional herniorrhaphy, reported
using a pre-operative dose of amoxicillin and clavulenic acid, results at an average follow-up of 51 months in the first 100
and, if the operation lasted longer than 2 h, another intra- patients. Major complications occurred in 4.1% of the
operative dose was given intravenously. Trophic ulcers patients with a recurrence of 9.3%. The major obstacles to
present in a small number of very large incisional hernias; success were mesh fixation which was achieved either with
they are usually situated at the most dependent area of the staples and tacks or through-and-through sutures to ensure
abdominal wall and occur as a result of ischaemia.27 Such secure peripheral fixation. The learning curve for the
ulcers are usually infected with Staphylococcus aureus and operation can be quite long and hazardous.30 Bencini and
should be treated vigorously with local wound care to Sanchez30 reported four bowel entries in their first 32 cases
eliminate gross infection before surgery (Fig. 3). together with three recurrences. The largest series to date
of nearly 400 cases was reported by Franklin and
colleagues31 who operated over a 10-year period with an
The laparoscopic approach
overall postoperative complication rate of 10.1% and
Laparoscopic incisional hernia repair is in its infancy.28 recurrence rate of 2.9%. Most surgeons will underlay the
Goodney and colleagues28 identified 83 studies comparing defect with no attempt to achieve fascial closure. Franklin et

254 Ann R Coll Surg Engl 2006; 88: 252260


KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

al.,31 however, described limited percutaneous closure of Erosion of the mesh may then occur into the intestines which
large defects and Chelala and colleagues32 strongly believe is a well-recognised drawback of this technique. However, the
that the linea alba should be reconstructed for functional and group from Angers, France have reported a series of 350
mechanical purposes to reduce extrusion of mesh within the patients operated between 1982 and 1999 in which the
hernial defect and reduce seroma formation. The closure of intraperitoneal placement of Dacron mesh was used as an
the defect is achieved either by intracorporeal non-reabsorbable aponeurotic graft.38 A 10-cm underlap was used when the
monofilament stitches or transparietal extracorporeal U-reverse mesh is placed in the peritoneal cavity and securing sutures
stitches to re-approximate the linea alba. Because mesh is in 34 cm apart of non-absorbable material placed through the
contact with bowel following the underlay techniques used in entire anterior abdominal wall. This repair is then covered by
laparoscopic repair, adhesion formation is a risk.33 Even with a musculo-aponeurotic abdominoplasty fashioned by incising
careful interposition of omentum, this occurs in at least one- the anterior lamina of the rectus sheath 4 cm from its medial
third of patients. edge and reflecting it inwards and suturing the edges
together. No fistulae were reported in this series with a
postoperative mortality of 0.6%, 2% wound infections and 2%
Open prosthetic mesh techniques
deep-seated infections that necessitated removal of the mesh.
Before the introduction of mesh, natural tissues were These outstanding results have not been repeated elsewhere
employed to repair large defects of the abdominal wall.34 and a smaller retrospective analysis carried out by de Vries
More than 50 years ago, Stock35 realised the potential of the Reilingh and colleagues39 compared the inlay technique
recent developments of plastics for the repair of large with onlay and sublay. In this series, the recurrence rate of
hernias. This was the result of a casual observation that
increasing quantities of fancy shoes with nylon mesh
uppers were appearing on the Hong Kong market and led Table 1 Classification for incisional hernias
him to investigate the use of this material as a potential
repair material for hernias. His initial cases were successful
LOCALISATION
and led Notaras36 to report on the use of Mersilene mesh, a
1. Vertical
braided polyester fibre, for the repair of incisional hernia.
1.1 Midline above or below umbilicus
Notaras used techniques which are still in use today: he
1.2 Midline including umbilical right or left
implanted the mesh deep to the rectus muscles (sublay)
1.3 Paramedian right or left
with its edges at least 2.5 cm beyond the edges of the defect
and administered antibiotics prophylactically with the use of 2 Transverse
closed suction drainage postoperatively.36 Other methods of 2.1 Above or below umbilicus right or left
deployment of prosthetic mesh include the prefascial 2.2 Crossed midline or not
subcutaneous or onlay method and the inlay method where
3. Oblique
the fascial edges are not approximated and the mesh lies in
3.1 Above or below umbilicus right or left
contact with the underlying viscera. Korenkov and
colleagues37 reported on the results of an experts meeting 4. Combined (midline + oblique; midline +
which summarised the results of the prefascial onlay parastomal, etc.)
prosthetic repair (seven studies) and the retromuscular
SIZE (= real fascial gap)
sublay technique (eleven studies). The complication rates and
1. Small (< 5 cm in width or length)
the recurrence rates were in the same range for both
2. Medium (5-10 cm in width or length)
techniques but there has never been a randomised study to
3. Large (> 10 cm in width or length)
investigate which is superior in the hands of general
surgeons. The sublay technique is, however, more com- RECURRENCE
plicated to perform and is less versatile because it is only 1. Primary
suitable for midline hernias. Korenkov and colleagues37 also 2. Recurrence (1, 2, 3, etc.)
devised a classification system for incisional hernias which REDUCIBILITY AT THE HERNIA GATE
can be useful in comparative studies (Table 1). 1. Reducible with or without obstruction
2. Irreducible with or without obstruction
The inlay technique
Polypropylene mesh anchors to all adjacent tissues and, SYMPTOMS
therefore, has the propensity for inducing extensive 1. Asymptomatic
adhesions to viscera if placed in a position where they 2. Symptomatic
become adjacent to bowel such as the inlay technique.

Ann R Coll Surg Engl 2006; 88: 252260 255


KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

Figure 5 Preparing the space behind the rectus muscle for a


sublay mesh.
Figure 4 Onlay mesh fixed with multiple continuous and quilting
sutures.

with materials other than polypropylene exhibiting larger


pore sizes in an attempt to produce a low-weight mesh. This is
inlay was 44% and 2 of 23 patients receiving inlay a complex operation and is only applicable to midline hernias
developed enterocutaneous fistulae at the edges of the and, in the lower one-third of this region, the mesh is only
mesh where constant friction had caused damage to the protected from bowel by tenuous peritoneum. Clinical trials
bowel. Inlay techniques are not generally recommended are awaited to see which of the three mesh techniques
unless there is a substantial defect in the tissue that cannot provides the best results in the hands of general surgeons.
be bridged with plastic procedures of the natural layers of The application of tissue glues between the muscle layers or
the abdominal wall (see below). between the fascial layers and subcutaneous tissue after
incisional hernia repair with polypropylene mesh has the
The onlay technique potential to reduce wound complications, such as seroma,
The onlay technique (Fig. 4) in which the mesh is placed and result in shorter hospital stay and less wound care.44 The
over the abdominal wall closure in the subcutaneous results of randomised trials are awaited.
prefascial space was refined and popularised by Chevrel.40
This technique is versatile and lends itself to repair of
structures other than defect in the midline of the abdominal
Components separation technique
wall. Chevrel also described relaxing incisions in the
anterior rectus sheath and the use of glues in an attempt to This operation (Fig. 6), devised by Ramirez and colleagues,45
reduce seroma formation. Other groups, however, have not allows a flap of the rectus muscle, anterior rectus sheath and
had the same success and San Pio and colleagues41 internal oblique transversus to be advanced in the midline a
performed the onlay technique with an 810 cm overlap maximum of 10 cm, i.e. incisional hernia gaps of 20 cm can
with 10% of patients having relaxation of muscles of the be closed. The external oblique is released from its
anterior abdominal wall. The recurrence rate at 5-year attachment to the rectus muscle and a plane dissected
follow-up was 15% and two patients died in the peri- between the external and internal oblique aponeuroses. An
operative period, one from pneumonia and one from bowel additional step is the complete release of the rectus
perforation. abdominus muscle from its anterior and posterior sheaths
by incising the posterior rectus sheath at its medial border
Sublay technique the so-called sliding door technique.46 An obvious
Another French group, Rives and colleagues,42 devised and prerequisite for this technique is the presence of
popularised this technique (Fig. 5) in which the mesh is undamaged rectus muscles. However, this technique will
placed over the closed posterior rectus sheath and allow the tensionless approximation of the rectus muscles
peritoneum. The rectus muscles are then allowed to fall into in large and recurrent hernias precluding the problem of
their natural position overlying the mesh and then the anterior abdominal compartment syndrome.47 Many surgeons
rectus sheath is closed (Fig. 2). Welty and colleagues43 became recommend the additional application of synthetic mesh in
the main protagonists for this technique and experimented an onlay position to supplement the attenuated layers of the

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KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

Tissue expansion assisted closure


An alternative method to components separation is the use of
tissue expanders placed in the subcutaneous or submuscular
space for a period of months in order to achieve tissue
expansion prior to hernia repair.50 This technique is
particularly useful in defects of the abdominal wall occurring
after major trauma, tumour ablation or congenital
abnormalities.

Contaminated wounds
In the acute situation, temporary closure of open abdominal
wounds can be achieved by the modified sandwich vacuum
pack technique.51 A 3-l plastic irrigation bag is sutured to
the wound edges and continuous high-pressure suction
applied to achieve temporary abdominal wall closure. This
is the so-called laparostomy (Fig. 7) popularly used in cases
of intra-abdominal sepsis, visceral oedema or compartment
syndrome. Closure of laparostomy wounds can then be

Figure 6 A 10-cm shift of the left rectus muscle into the midline
after components separation of the external oblique aponeurosis
from its attachment to the lateral border of the rectus muscle.

anterior abdominal wall.48 In a relatively large series of 43


patients, de Vries Reilingh and colleagues49 were unable to
reproduce the good results of Ramirez and recorded
recurrent hernia in 32% of patients at 15-month follow-up.

Figure 8 Split skin graft applied to laparostomy wound (and co-


Figure 7 Granulating laparostomy wound.
existing stoma constructed after anastomotic leak and sepsis).

Ann R Coll Surg Engl 2006; 88: 252260 257


KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

achieved in two ways: (i) in stages by removing the plastic laparoscopic repair because of the good working space in
irrigation bag, allowing the wound to granulate, applying the epigastric region.
split skin grafts (Fig. 8) and finally attempting definitive Trocar site hernia has recently been reviewed by Tonouchi
reconstruction; or (ii) in a one-stage operation using the and colleagues.64 Sixty-three reports were reviewed and, as a
components separation method.52,53 The adoption of either result, a classification system was devised dividing these hernias
of these methods, however, requires advanced skills in into three types:
abdominal wall reconstruction and should only be
1. Early onset occurring immediately after the operation
undertaken by skilled teams of surgeons.
with a high susceptibility to small bowel obstruction
due to Richters type hernia.
Loss of domain
2. Late onset hernias occurring more than 30 days after
Loss of domain (residence) implies that a proportion of the operation or up to several months, presenting as a local
abdominal contents reside permanently (in a hernia sac the abdominal bulge and rarely causing small bowel
second abdominal cavity) outside their natural compartment; obstruction.
returning these contents will require significant physiological
3. A special type in which the whole trocar site dehisces
adaptation (mainly respiratory) if the volume exceeds more
with protrusion of intestine and/or omentum. The inci-
than 1520% of this compartment.54 Such hernias are a
dence is estimated to be between 0.652.8% with an
challenging surgical problem and require careful patient
increasing risk for larger trocar sites.
selection and surgical technique with a team involving
anaesthetists and plastic surgeons, postoperative care in ITU The authors recommend that all 10-mm trocar sites should
and careful pre-operative preparation including considerable be closed under direct vision and also smaller trocar sites
weight loss. The components separation technique is a that have been forcibly dilated, for instance, to remove the
valuable adjunct in patients with loss of domain. gall bladder.
Traumatic abdominal wall hernias are rare and
represent only about one in 10,000 hernias.65 They are
Unusual sites
commonly misclassified and should only be regarded as
Parastomal hernia affects 1.828.3% of end ileostomies and up traumatic if they appear soon after the episode of trauma
to 6.2% of loop ileostomies. Following colostomy formation, when there has been no skin penetration or no previous
the rates are 4.048.1% and 0.331%, respectively.55 Direct herniation at this site. There is often an association with a
tissue repair or stoma relocation have recurrence rates of up to tear in the intestinal mesentery.
50% although the use of mesh lowers this considerably to Patients with incisional hernias in kidney transplant
between 025%.56 However, mesh placed in this onlay position incisions present special problems.66 The external oblique
around the stoma as a circumferential onlay can cause muscles are usually intact while the hernia sac is located
problems of erosion into the stoma or fistula formation in up to between the deeper layers of the abdominal wall. Surgical
5% of patients.57 Jones et al.21 have recently reported the use of exploration must, therefore, be meticulous and the recom-
prophylactic mesh in the prevention of parastomal hernia by mended mesh placement technique after repair is by the
the placement of a lightweight sublay mesh at the time of onlay method.
stoma formation. Repair of large abdominal wall hernias in pre-
Lumbar hernias are another particularly difficult hernia menopausal women presents special problems because of
to repair because of the location over the flat lateral mus- the requirement to allow subsequent pregnancy with elas-
cles of the abdominal wall often accompanied by concomi- ticity and expansion of the abdominal wall. In these cases,
tant nerve damage resulting in muscle atrophy.59 The tech- it maybe better to avoid mesh and use sutured repair such
nique described by Carbonell solves the problem of repair- as the shoelace technique.67
ing this type of hernia with the use of bone anchors.
A similar concept has been applied to the repair of iliac
The future
crest hernias occurring through donor sites for bone grafts.6062
Herniation occurs where the full thickness of the iliac bone has The application of three-dimensional stereography to
been removed and fixation of mesh can be achieved by an measure abdominal wall mobility and function is improving
anchor device utilised in orthopaedic surgery. our understanding of abdominal wall compliance prior to
Subxiphoid incisional hernias occurring after median surgery and after the placement of prosthetic mesh.68
sternotomy are a problem occurring after wound infection.63 Knowledge of the maximum tensile strength and the
Mesh repair with fixation to rib periosteum is recommend- dynamics of distension will enable the design of prosthetic
ed although this hernia may be particularly suitable to mesh materials which are more physiologically compatible

258 Ann R Coll Surg Engl 2006; 88: 252260


KINGSNORTH THE MANAGEMENT OF INCISIONAL HERNIA

than those currently used.69 However, it is the surgeon and 21. Jones A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a prosthet-

the techniques used that are of paramount importance in ic mesh. Arch Surg 2004; 139: 13568.

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hernias: imaging with spiral CT. Eur Radiol 2000; 10: 9149.
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260 Ann R Coll Surg Engl 2006; 88: 252260

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