Rcse8803 252 PDF
Rcse8803 252 PDF
Rcse8803 252 PDF
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
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.
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.
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
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.
the repair of abdominal incisional hernias. 22. Stabile Ianora AA, Midiri M, Vinci R, Rotondo A, Angelelli N. Abdominal wall
hernias: imaging with spiral CT. Eur Radiol 2000; 10: 9149.
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