268_2007_9118_32_1-web 31.36

Open Mesh Repair of Incisional Hernia Using a SublayTechnique: Long-Term Follow-up Martin Kurzer Æ Allan Kark Æ Simon Selouk ÆPhilip Belsham Published online: 4 July 2007Ó Socie´te´ Internationale de Chirurgie 2007 Open repair of incisional hernias with mesh Reported results of incisional hernia repair in the subfascial plane is highly effective with acceptable are poor with high recurrence rates unless prosthetic mesh complication rates. Surgeon experience and a team ap- is used. Mesh gives improved results, but certain tech- proach are important factors in obtaining good results.
niques are associated with a high incidence of infections, Trials comparing open with laparoscopic repair are needed.
fistulas, and seromas. This study reports the results of aconsecutive series of incisional hernias repaired using an The development of an incisional hernia is a significant open sublay technique with retromuscular mesh placement.
complication of laparotomy, with an (estimated) incidence The primary endpoint was hernia recurrence. Secondary between 10% and 15% Apart from the risk of bowel endpoints were complications and long-term discomfort.
strangulation, it has an impact on patients’ quality of life.
A total of 125 patients were operated on be- The reported results of incisional hernia repair vary widely, tween 1991 and 2001. In 2002 they were sent a question- with high recurrence rates for sutured repair alone [ naire and asked to return for examination if they thought Using prosthetic mesh gives improved results [, , their hernia had recurred or if they had pain. A second but the positioning and type of mesh used are critical factors, questionnaire was sent in 2005, and all patients were asked and certain techniques are associated with a high incidence of complications (infection, fistula, seroma) []. Cur- There were no postoperative deaths and no major rent debate focuses on whether the mesh repair should be systemic complications. There were no early (within 30 laparoscopic or open , ] and, if open, in which days) wound infections; the mesh subsequently became abdominal wall plane the mesh should be placed. This study infected in two patients and had to be removed. Seromas reports the results of a prospective series of consecutive developed in 12 patients. In 2002, a total of 106 ques- incisional hernias repaired using an open technique and tionnaires were returned; 3 patients had died of unrelated retromuscular mesh placement (sublay technique). The causes, and 16 were untraceable despite repeated attempts.
primary endpoint was hernia recurrence. Secondary end- There were five (4%) recurrences. Altogether, 6 patients points were complications and long-term discomfort.
had abdominal wall discomfort, and 49 patients spontane-ously wrote that they were pleased or very pleased with thelong-term result. At a second follow-up a mean of 8 years after operation (95 months; range 46–168 months) patientswere assessed by an independent observer, and there were Between 1992 and 2001, a total of 125 patients underwent repair of an incisional hernia following an operation else-where. A prospective database was maintained, and thedemographic data are listed in Table Patients wereconsidered unsuitable for surgery and were not operated on M. Kurzer (&) Á A. Kark Á S. Selouk Á P. Belsham if they had a body mass index (BMI) >40, an American British Hernia Centre, 87 Watford Way, Hendon NW4 4RS, UKe-mail: [email protected]; [email protected] Society of Anesthesiologists (ASA) score of 3, or chronic No. of previous repairs of incisional hernia BMI: body mass index; ASA: American Society of Anesthesiologistsscore pulmonary or ischemic heart disease. A total of 106 hernias followed vertical midline incisions, 3 were subcostal, 8 gridiron appendectomy, 5 Pfannenstiel, 2 transverse abdominal, and 1 followed a transverse rectus abdominismuscle (TRAM) flap for breast reconstruction. In 81 pa-tients (65%) the diameter of the defect was ‡15 cm; in theremainder it was 5 to 14 cm. A group of 46 patients (37%)had undergone a previous repair of their hernia elsewhere.
Mesh had been used before in six cases (Table ).
All operations were carried out under general anesthesia.
Graded compression stockings were fitted, and intermittentcalf compression was used intraoperatively. No patientswere anticoagulated. Patients received a single dose ofintravenous broad-spectrum antibiotic (a cephalosporin) atinduction and two more doses 8 and 16 hours later. Theskin preparation was performed with alcohol-based povi-done-iodine.
The open sublay technique , ] was used by the Fig. 1 Mesh in retromuscular preperitoneal position three operating surgeons (M.K., A.K., P.B.). After openingthe old incision, the peritoneal cavity was entered and thesac separated from the surrounding tissue to define the edge itself, or excess sac. In five cases Vicryl (polyglactin; of the fascial defect. Wide undermining of the subcutane- Johnson & Johnson, Piscataway, NJ, USA) mesh and in ous tissue was not done. Local adhesions to the edges of the three cases omentum was used to separate intraabdominal sac were divided, and the inside of the length of the scar contents from the polypropylene mesh.
was palpated to exclude secondary defects. Excess sac was Standard weight polypropylene mesh was placed in the preserved. If mesh had been used previously it was not prepared submuscular space and trimmed to a size that removed unless it obviously interfered with the new mesh allowed it to cover the whole area to the limits of the dissection, with an overlap of at least 5 cm and at least 5 The medial edge of each rectus muscle was identified by cm above and below the top and bottom of the fascial palpation, and the extreme medial edge of each rectus sheath was incised along its length to enter the submuscular The mesh was secured with interrupted 2/0 polypro- space. This relatively bloodless plane could be developed pylene sutures placed 5 cm apart at the limits of the dis- easily to the lateral edges of the rectus muscle on each side.
section (i.e., the junction of the lateral edge of the rectus Primary ‘‘peritoneal’’ closure was obtained using pos- muscle with the posterior sheath). Care was taken to avoid terior rectus sheath above the arcuate line, the peritoneum inadvertently entering the peritoneal cavity and piercing There were five (4%) recurrences, and all had been noticed by the patients prior to the follow-up visit. Mild discomfort was reported by six patients, either centrally or near the edge of the mesh attachment, although it did not affect their level of activity or quality of life, nor did they need to take analgesics. Altogether 49 patients (46%) spontaneously wrote or stated that they were pleased or very pleased with the results. On direct questioning, seven Major complications (cardiac, pulmonary, neurological, patients (5%) expressed a degree of dissatisfaction because In 2006, another 122 questionnaires were sent out, and 76 were returned—at a mean follow-up of just under 8 years (95 months) (median 84 months, range 46–168months). Another 26 patients were untraceable, and 4 pa- the bowel. The anterior rectus sheath was closed using tients had died. Altogether, 56 patients attended for continuous 2/0 polypropylene. If this could not be done assessment by an independent observer (S.S.). Because of without tension, the medial edges were not brought to- travel difficulties (some lived abroad), the remainder were gether but, instead, sutured to the polypropylene mesh interviewed on the telephone (by S.S. or M.K.). No more where they lay. Two suction drains were placed in the recurrences were discovered at this second follow-up, and subcutaneous space, and the skin was closed with a sub- no patient had developed discomfort since the previous Patients were mobilized the following day. Opiate analgesics were not needed after 24 hours.
The results following repair of incisional hernias vary Patients were seen routinely 2 weeks and 3 months post- widely ]. There is now ample evidence that sutured operatively and at other times if needed. They were sent a repairs have a recurrence rate as high as 50%, even those questionnaire in 2002. They were also asked to return for for small defects , ]. Repairs using pros- examination if they thought their hernia had recurred or if thetic mesh have a lower reported recurrence rate [, ] but they had pain. A second questionnaire was sent in 2005, may give rise to high complication rates [, , and all patients were asked to return for examination. The At the time this prospective study commenced, we were examination was carried out by an independent surgeon convinced by the evidence in the literature that an open (S.S.) not involved with their clinical management or their mesh method gave better results than simply suturing the defect –Hence, we did not believe that subjectingour patients to a comparative trial was justified.
The most important criterion for a successful repair must be the failure rate, and our recurrence rate of 4% at the firstfollow-up at 4 years after operation compares favorably There were no postoperative deaths, no major systemic with other series of open sublay repair, with reported complications (Table and no early (within 30 days) recurrence rates ranging from 0 to 20% [–]. A wound infections. In two patients the mesh subsequently number of these studies had a relatively short follow-up became infected (at 4 months and 15 months, respec- period. A recent nationwide survey of surgical practice and tively) and had to be removed. Clinically detectable se- results in Sweden revealed a recurrence rate of 29% with romas developed in 12 (10%) patients, but aspiration was sutured repair, 19% with onlay repair, and 7% after sublay required in only 2. In 2002, the 125 patients were written repair at a follow-up of less than 2 years []. Our mean to, and 106 questionnaires (81%) were returned. The follow-up period was 8 years, although we are aware that a mean follow-up period was 47 months (6–120 months).
drawback with our series is the incomplete follow-up, Three patients had died of unrelated causes, and sixteen which is shared by most such long-term studies and reflects were untraceable despite repeated attempts. Symptomatic the scattered geography of our patients. As Burger et al.
patients were specifically requested to return for an have pointed out, long-term follow up is essential, although examination, and the remainder were offered an exami- they were able to contact only 70% (126/181) of their initial group [, We were interested to find that at our second follow-up visit there were no more recurrences.
the anterior sheath can be closed, the mesh is then also This is similar to our experience and that of others with separated from the subcutaneous tissues. In contrast, with mesh inguinal hernia repairs where late recurrences are an onlay mesh, the repair is less mechanically sound as abdominal wall forces tend to push the mesh off the repair The literature regarding late recurrence is contradictory.
]. In addition, onlay mesh requires extensive subcuta- With nonmesh sutured repairs, most recurrences appear neous dissection, increasing the risk of hematoma, seroma, within 3 years , , However, there is evidence and infection; it is associated with a high incidence of local that recurrences following mesh repairs continue to occur for many years after the initial procedure [, ]. Lateral Meeting [conclusion was that it was technically simpler mesh detachment at the edges of a defect and inadequate than the sublay repair and could be used by surgical resi- mesh overlap are thought to be the likeliest reasons for dents. As has recently been pointed out, onlay mesh is recurrence after mesh repair ]; thus, secure attachment frequently used simply as an adjunct to a standard sutured of the mesh with a large enough overlap of the defect repair, rather than a planned procedure of choice At should prevent late recurrence. It is noteworthy that in one present, there are no comparative trials of sublay versus of the few randomized controlled trials comparing sutured versus mesh repair the cumulative failure rate following Few studies have specifically addressed the question of sublay mesh repair was 32%, and the mesh overlap was long-term discomfort or patient satisfaction. The incidence only 2 cm. A recent study of high-risk, technically chal- of long-term discomfort in our study was 6%, and 49% of lenging patients with high BMIs and large incisional her- patients spontaneously stated that they were pleased with nias reported low recurrence rates following sublay mesh the result. Seven patients expressed a degree of dissatis- and emphasized the importance of a subfascial mesh faction because of discomfort or cosmesis—possibly re- overlap of at least 7 cm ]. The importance of a skilled lated to unrealistic expectations. Postoperative discomfort team and surgeon experience are recognized to be major has been noted by others, with an incidence ranging be- factors in achieving good results with mesh incisional hernia repair [Langer et al. found that a min- be related to attaching the mesh at the lateral border of the imum of 20 incisional hernia repairs were generally re- rectus muscle [or directly attributable to the mesh being quired to achieve a recurrence rate of less than 10% [ infiltrated by inflammatory cells with subsequent scar tis- The trial of Burger et al. was a multicenter one involving an unspecified number of surgeons of varying None of our patients developed an early (<30 days) experience. Confining repairs to the most experienced wound infection or other local wound problems, although surgeons would possibly have resulted in lower recurrence our series included no massive hernias with loss of domain, rates. Le and Bender [reported a 2% recurrence rate thin ischemic skin, or trophic ulcers. In most series of following 150 subfascial mesh repairs carried out by a sublay repairs, the incidence of wound infection is reported at <10% [, , ]. Overall mesh infection Although an effective technique must have a low inci- rates can vary widely, however, depending perhaps on dence of recurrence, other outcomes should be assessed as patient and hernia factors, operative technique, and the type well. Additional important factors include the technical difficulty for the operator, frequency and seriousness of We believe that a major factor in the development of general and local wound complications, postoperative pain, postoperative wound complications relates to tension in the repair. Closing the defect under tension leads to excessive With open repairs, placing mesh in the submuscular or early postoperative pain, ischemia, and suture cut-out; and sublay position is claimed to be technically difficult [ it provides an ideal environment for bacterial growth and This is not our experience. It may be slightly more subsequent infection. Lateral relaxing incisions have been challenging but not beyond the competence of a trained used [but we believe this introduces an unnecessary general surgeon. We were also able to use the submuscular complicating factor. Not bringing the edges of the rectus technique, with modification, to repair hernias with sub- sheath together if this requires excessive tension is an ac- costal, gridiron, and Pfannenstiel incisions. Placing mesh in cepted technique that has been used successfully in other this plane has mechanical and physiologic advantages.
Intraabdominal pressure tends to push the mesh firmly Although 12 of our patients (10%) had clinically against the adjacent abdominal wall (Pascal’s principle of detectable seromas, only 2 (<2%) were symptomatic and hydrostatics) [A large overlap gives a sufficient sur- required aspiration. Seromas are said to be a common face area for tissue ingrowth and firm fixation, providing problem following sublay mesh incisional hernia repair, strong reattachment for the lateral abdominal muscles. If with an incidence of up to 30% []. The incidence can be as high as 70% when routine ultrasonography is 2. Kingsnorth A, LeBlanc K (2003) Hernias: inguinal and inci- applied to the search, although they rarely present a major 3. Mudge M, Hughes LE (1985) Incisional hernia: a 10 year pro- management problem [They are much commoner and spective study of incidence and attitudes. Br J Surg 70:70–71 more troublesome after onlay repair with subcutaneous 4. Burger J, van ‘t Riet M, Jeekel J (2003) Abdominal incisions: mesh and a wide subcutaneous dissection , ].
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