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Incisional hernias develop in up to 11% of surgical abdominal wounds with a possible recurrence following repair of 44%. We describe our experience with a combined fascial and prosthetic mesh repair. Thirty-five patients (16M:19F) have been treated. The original operation was bowel related in 19 cases, gynaecological in 8, hepatopancreaticobiliary in 3 patients, aortic aneurysm repair in 2 and involved a thoraco-laparotomy in 3. The incisions were midline in 26 cases, transverse in 6, paramedian in 2 and rooftop in one patient. The hernias were considered subjectively to be large in 15, medium in 14 and small in 6 of the patients. A proforma was completed for each patient noting intra-operative and post-operative complications, post-operative hospital stay and analgesic requirements. Post-operative complications included seroma formation in 6 patients, deep vein thrombosis in one and a non-fatal pulmonary embolism in another. One patient developed a wound haematoma and one had a superficial wound infection. Post-operative in-hospital stay ranged from 1 to 27 days with a mean of 6.2 days. Of the 35 patients 33 were available for follow-up. Follow-up was for a median of 20.3 months (range 6.0 to 54.1 months). Two of these (6%) patients reported a persistent lump and one (3%) reported persistent pain but none of the remaining 33 was found to have a recurrence. We advocate this technique because it is applicable to all hernias, most of the mesh is behind the rectus sheath and has 2 points of fixation, it is relatively pain-free allowing early mobilisation, has a modest complication rate and a low recurrence rate.
Keywords: incisional hernia, prosthetic mesh
J.R.Coll.Surg.Edinb., 46, February 2001, 39-43
Incisional hernias develop in 3.8-11.5 % of patients after abdominal surgery.1,2 The incidence depends on a number of factors including old age, male sex, obesity, bowel surgery, suture type, chest infection, abdominal distension and wound infection.1 Ninety percent of incisional hernias occur within 3 years of operation.2
Repair of large abdominal incisional hernias is a difficult surgical problem with recurrence being a common outcome. Recurrence rates of up to 33% after first repair and 44% after second repair have been reported3 - most occurring within 3 years of the repair.3,4 Numerous methods of repair have been described - primary repair in one or two layers or Mayo-type overlap, use of fascia (local or flaps) with suture darns, and the use of fascia with synthetic mesh (polypropylene or Marlex mesh, stainless steel, mersilene or expanded polytetrafluoroethylene).3,5-20 In a literature review Loh et al (1992) state that overlapping techniques produce impressive results and that techniques combining fascia with mesh have the advantage of overcoming excessive tension.11
We describe our experience with a technique using fascia and polypropylene mesh, originally described by Browse and Hurst (1979).12 This technique was initially used in the repair of long midline incisional hernias but subsequently was applied to subcostal hernias by Whiteley et al (1998).17 Our modification involves the introduction of an overlap and two points of anchor for the mesh.
All patients received anti-thrombotic prophylaxis in the form of compression stockings, subcutaneous heparin and the use of flowtron boots per-operatively. All operations were performed under a general anaesthetic. After skin preparation and draping the cutaneous scar was excised and the hernia sac dissected to expose the circumference of the abdominal wall defect (Figure 1). The sac was opened only if there was a definite history of obstruction or if the sac was irreducible. The rectus sheath or external oblique aponeurosis was clearly exposed around the circumference of the defect. It was then incised at a distance from the edge of the defect judged to allow apposition of the lateral margin of the medial leaves after mobilisation. The medial leaf was then elevated from the underlying muscle (Figure 2) and its lateral margins sutured with continuous 0 polydioxanone (Figure 3) inverting the sac and in the case of midline hernias providing a midline fascial layer. In the case of transverse incisions care was taken to ensure that the circumferential incision had aponeurotic or fibrous scar tissue on either side. In midline hernias the lateral leaf of the rectus sheath was then elevated from the underlying muscle. In transverse hernias the mesh was sutured to the under surface of the external oblique muscle with loose interrupted polydioxanone sutures (Figure 4). The medial border of the lateral leaf of the rectus sheath, or the fibrous margin of the lateral circumference of a transverse defect, was then sutured to the upper surface of the mesh with continuous polydioxanone to give a tension-free repair (Figure 5). Two suction drains were inserted and the skin closed with subcuticular vicryl. All patients received three doses of intravenous cefuroxime (750 mg). The drains were removed when there was less than 50 ml of drainage in 24 hours. Post-operatively, the patients were mobilised as soon as possible and discharged home once the drains had been removed.
Figure 1: Diagrammatic representation of the incisional hernia
Figure 2: The medial leaf of the divided rectus sheath is dissected free and reflected medially
Figure 3: The margins of the medial leaf of the rectus sheath are sutured together inverting the sac. The lateral leaf is dissected free of the underlying muscle
Figure 4: A sheet of Marlex“ mesh is sutured to the undersurface of the lateral rectus sheath
Figure 5: The lateral leaf of the rectus sheath is sutured to the Marlex“ mesh. The wound is then closed over suction drains
Thirty-five consecutive patients were evaluated (16 men and 19 women). Their median ages were 68 years for men and 54.5 years for women. The original operation was bowel related in 19 patients, gynaecological in eight, hepatopancreaticobiliary in three, aortic aneurysm repair in two and involved a thoraco-laparotomy in three cases. The original incisions were midline in 26 patients, transverse in 6, paramedian in two and rooftop in one case. The size of the incisional hernia was subjectively considered to be large in 15, medium in 14 and small in six patients. Six patients had had a previous attempt at hernia repair. A proforma was completed for each patient noting intra-operative and postoperative complications, post-operative hospital stay and analgesic requirements. Analgesic requirements were noted from the prescription chart. The number of doses of the individual analgesic was noted (one dose of diclofenac sodium was 100 mg, one dose of co-proxamol was two tablets and one dose of morphine was 10 mg intramuscular injection). Follow-up data was compiled from clinic visits and telephone surveys.
There were no intra-operative complications but one patient was electively ventilated for 24 hours because the hernia was very large and irreducible. One patient was noted at operation to have an abdominal aortic aneurysm, which was repaired at a later date, with an abdominal incision through the mesh. One patient underwent the hernia repair combined with an anterior pelvic floor repair.
Post-operative complications are shown in Table 1. Seroma formation was the commonest problem with one patient requiring repeat aspirations and another requiring excision of a seroma cavity 5 months later. Despite full prophylaxis one patient developed a deep vein thrombosis and another had a non-fatal pulmonary embolism. A wound haematoma developed in a patient on warfarin. There were no cases of post-operative ileus. Post-operative in-hospital stay ranged from 1 to 27 days with a mean of 6.2 days (the patient who stayed for 27 days did so because of problems related to the anterior pelvic floor repair).
Table 1: Post-operative complications occurring in the 35 patients
| Complication | Number (%) |
|---|---|
| Seroma formation | 6 (17) |
| Wound haematoma | 1 (3) |
| Superficial wound infection | 1 (3) |
| Urinary retention | 1 (3) |
| Deep vein thrombosis | 1 (3) |
| Non-fatal pulmonary embolus | 1 (3) |
Post-operative analgesia requirements come according to the subjective size of the hernia, as shown in Table 2. It can be seen that the larger hernias required more opiate analgesia with four patients requiring a continuous background infusion of morphine in the form of patient controlled analgesia (PCA) for one day only and another patient requiring an epidural for 3 days. PCA was commenced electively in these four patients.
Table 2: Post-operative analgesia requirements. The median number of doses and the ranges are given
| Size of hernia | Diclofenac Sodium | Co-Proxamol | Morphine | Other |
|---|---|---|---|---|
| Small | 0.5 (0-6) | 4.0 (0-8) | 0 (0-2) | - |
| Medium | 2.5 (0-7) | 1.5 (0-14) | 0 (0-4) | - |
| Large | 0 (0-14) | 8.0 (0-15) | 1 (0-6) | 4 PCA 1 EPA |
PCA: patient controlled analgesia; EPA :epidural analgesia
In all patients the wound healed without problems. Of the 35 patients studied, 33 were available for follow-up. Follow-up was for a median of 20.3 months (range 6.0 to 54.1 months). Two of these (6.1%) patients reported a persistent lump and one (3.0%) reported persistent pain but none of the 33 patients were found to have a recurrence.
The use of a prosthetic mesh to repair large incisional hernias is well established. Different techniques have been described including a ‘sandwich’ of mesh and rectus sheath with overlapping and two points of fixation, mesh placed deep to the rectus sheath with overlap and mattress suture fixation, a complex ‘mesh-peritoneal sandwich’, fixation of a large mesh anterior to the rectus sheath with two points of fixation, and a combination of fascia and mesh.4,12-15,17 It has been suggested that overlapping leads to a better repair when one considers using fascia alone or in combination with mesh.4,13-15,19-21 Langer and Christiansen (1985) compared their results using primary repair with historical data using a mesh and suggested that the use of mesh gave a better repair with less recurrence.3 Loh et al (1992), in their literature review, suggested that the better results with mesh were simply a manifestation of inadequate length of follow-up and, furthermore, they highlighted a number of complications associated with the use of a mesh. 11 Liakakos et al (1994) carried out a prospective comparison of primary closure against the use of mesh and showed that the recurrence rate was less with mesh at a mean of 7.6 years of follow-up.16
Their patients, however, were not randomised. Our method has incorporated a fascial repair with the mesh placed behind the anterior leaf (thus, most of the mesh is covered) of the rectus sheath with considerable overlap and two points of fixation. This method has been used for hernias arising from incisions other than those in the midline.17
Wound infection is a potentially major complication which, fortunately, is usually superficial but can be severe enough to necessitate removal of the mesh.14
Matapurkar et al (1991) reported no seroma formation because their mesh was incorporated into a peritoneal sandwich.14 Formation of seroma was reported to be 4% by Molloy et al (1991), 6% by Lewis (1984) and 5.8% by Usher (1962), despite the subcutaneous position of the mesh and the extensive dissection involved.15,22,23 Jacobs et al (1965) reported a 45% seroma rate whether suction drains were used or not.24 They noted that accumulation of serum occurred 3-17 days after operation and that this complication was easily managed by multiple aspirations and usually subsided within 1 week. Usher (1962) reported a 1.6% incidence of seroma formation after inguinal hernia repair with a mesh and suggested this lower rate was due to the deeper position of the mesh.23
We found no recurrences at a median follow-up of almost 21 months. Previous studies have shown that 70-75% of recurrences develop within 2 years and 80-90% develop within 3 years.2-4 Our follow-up, therefore, is probably not long enough and should be extended for at least another year. None of the published studies concentrate on analgesia requirements. We found increased requirement of opiates in the larger hernias. PCA was used electively and discontinued early. The overall opiate analgesic requirement was low. Most patients managed with simple oral analgesics.
In summary, we advocate this method of incisional hernia repair as it is applicable to all sites of incisional hernia, the mesh is mostly hidden behind the rectus sheath and is anchored with two points of fixation, there is relatively little pain allowing for early mobilisation, the complication rate is low and there is a low recurrence rate.
Copyright date: 11th December 2000
Correspondence: Mr H. S. Khaira, Department of Surgery, Good Hope Hospital NHS Trust, Rectory Road, Sutton Coldfield B75 7RR, U.K.
©2001 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.