Combined faschia and mesh closure

M. S. WHITELEY, S. B. RAY-CHAUDHURI AND R. B. GALLAND
Department of Surgery, Royal Berkshire Hospital, Reading, UK

Large incisional hernias of the abdominal wall represent substantial defects of supportive tissues. The repair of these requires the mobilization of fascia or the use of a prosthetic mesh. A method for closing large midline incisional hernias using both the fascia and a mesh was described in 1979. This repair was used for six midline hernias and four large incisional hernias in the right subcostal region. No wound complications and no recurrences (median follow-up 1 year 5 months) were seen. The combined fascia and mesh repair can be successfully used for large incisional hernias of the anterior abdominal wall in areas other than the midline.

Incisional hernias develop in up to 11% of surgical abdominal wounds.^1,2 Recurrence after repair has been described in up to 44% of patients.³ If the deficit is small, simple closure without tension is all that is required. However, when the defect is too large to close by simple mass closure, repair using prosthetic material may be required.

We describe our experience with a technique which combines a fascial with prosthetic repair. Originally this was described for long, large midline hernias, but we have used it successfully for large right subcostal hernias.

The skin and subcutaneous fat are divided and the edges of the defect defined (Figure 1).

Figure 1 Anatomy of the incisional hernia. Shaded area is muscle with the fascial layer anteriorly made op of rectus sheath and aponeurosis of external oblique. The hernial sac is seen protruding through the defect in the muscle and fascia.

The hernia is reduced without opening the peritoneal cavity and a circumferential incision is made down to muscle 2—5cm from the edge of the neck (Figure 2).

Figure 2 Incision in the anterior fascial layer down to muscle, 2—5 cm from the hernia neck.

The larger the hernial neck, the further from the edge this incision is made. The medial edges of the fascia are sewn together with 1 nylon or 0 polypropylene over the hernia (Figure 3). This provides a tension-free fascial layer, reducing the hernia.

Figure 3 Anterior fascia flapped medially to meet the fascial flap from the other side. 1 Nylon or 0 polypropylene closure of fascia, reducing the hernia and giving a tension-free fascial closure of the defect. However, muscle of the anterior abdominal wall (shaded area) is now exposed to superficial structures and is without fascial support.

The fascial defect that has been formed by this manoeuvre is repaired using a tension-free polypropylene mesh that is sutured to the free edge of the fascia around its circumference (Figure 4). After the insertion of a vacuum drain, the subcutaneous layers are closed and the skin sutured with continuous subcutictilar polyglycolic acid. The procedure is carried out under prophylactic antibiotic cover.

Figure 4 Polyprolene or Marlex mesh repair (dark shading) of the fascial defect using 1 nylon or 0 polypropylene.

We have used this technique in 10 patients with large incisional hernias. In six of these patients the defect was a midline incisional hernia, although in four patients the large incisional hernia was secondary to a right subcostal incision for open cholecystectomy. There have been no wound complications and no recurrence at a median follow-up of l year 5 months.

The use of a synthetic mesh to repair large primary or recurrent incisional hernias is well established. The usual way of using mesh is to open the sac, separate the bowel from the neck of the sac and suture the mesh to the edges of the hernia so defined.^4,5Molloy et al. described a technique for closing massive incisional hernias with Marlex mesh⁶ that involved opening the sac and then applying the mesh directly onto the defect, albeit with a 10 cm overlap and two rows of sutures. In such techniques it may not always be possible to separate the bowel from the mesh by using the omentum or peritoneum. Thus there is the possibility of the gut becoming adherent to, and damaged by, the mesh. Similarly, the gut may be damaged d tiring dissection of the sac.

The technique used in this series was first described by Browse and Hurst⁷in 1979 for use in long midline incisional hernias. We have found it useful for both these and other large incisional hernias such as subcostal wounds after open cholecystectomy. This technique avoids the potential complications described earlier. It is an easy procedure to perform and produces a tension-free, two-layer repair. We believe that the formation of the deeper fascial layer is an advantage over the one-layer mesh repairs where the mesh lies directly on the peritoneum or abdominal contents.

We have experienced no wound problems or problems associated with the mesh. There has been no evidence of recurrence. We suggest that this is a useful technique for the repair of large abdominal incision hernias and should not necessarily be restricted to those in the midline.

Correspondence: Mr R. B. Galland, Department of Surgery, Royal Berkshire Hospital, London Road, Reading RU] 5AN, UK.