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Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 226-229

Evaluation of retromuscular mesh repair technique for treatment of ventral incisional hernia

Department of General Surgery, Menoufiya University, Menoufiya, Egypt

Date of Submission12-Feb-2013
Date of Acceptance13-May-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Hazem M Goda El-Santawy
MBBCh, Gad St from Gamal Abd El-Naser St, Shebin El-Kom, Menoufiya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.141640

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Incisional hernia is a common surgical condition with a reported incidence of 2-11% following all laparotomies. Results of tissue repair have been disappointing. The optimal approach for abdominal incisional hernias is still under discussion.
The aim of the study was to evaluate the retromuscular mesh repair technique in the treatment of ventral incisional hernia as one of the standard techniques for treatment of such cases.
Materials and methods
This prospective study on 52 consecutive patients was performed from July 2010 to February 2013. Patients were prepared to be operated by the retromuscular mesh repair technique. All patients were evaluated with respect to operative time and postoperative complications. Results were documented and statistically analyzed.
In this study on 52 patients, there were 37 female patients (71.2%) and 15 male patients (28.8%). The age of the studied patients ranged between 20 and 61 years with mean age of 45.4 years. The mean operative time was 84.88 ± 18.04 min. The mean period of drainage was 3.1 ± 0.9 days. Seroma was not encountered in any patient. No recurrence was reported in the studied patients during the period of follow-up (12-30 months).
On the basis of this study, we conclude that retromuscular (sublay) mesh repair is the ideal technique for incisional hernia repair.

Keywords: Incisional hernia, mesh repair, preperitoneal, retromuscular, sublay

How to cite this article:
Goda El-Santawy HM, El-Sisy AA, El-Gammal AS, El-Kased AF, Sultan HM. Evaluation of retromuscular mesh repair technique for treatment of ventral incisional hernia. Menoufia Med J 2014;27:226-9

How to cite this URL:
Goda El-Santawy HM, El-Sisy AA, El-Gammal AS, El-Kased AF, Sultan HM. Evaluation of retromuscular mesh repair technique for treatment of ventral incisional hernia. Menoufia Med J [serial online] 2014 [cited 2020 Sep 21];27:226-9. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/226/141640

  Introduction Top

Incisional hernia is defined as a defect occurring through the operative scar. It is the only hernia considered to be truly iatrogenic. It occurs because of the failure of the lines of closure of abdominal wall following laparotomy [1],[2]. An incisional hernia occurs when all the layers except the skin fail to heal. It is one of the most common conditions requiring major surgery, despite advances in surgical techniques and suture material. The incidence of incisional hernia in the literature is 2-11% following all laparotomies [3], and it is a source of morbidity and requires high healthcare costs.

Factors associated with formation of incisional hernias are grouped into those that impair wound healing, such as wound infection, diabetes, corticosteroids use, smoking, connective tissue disorders, malignancies, radiotherapy, multiple surgeries, and advanced age; conditions that increase intra-abdominal pressure, such as obstructive airways diseases, constipation, lower urinary tract obstruction, pregnancy, and ileus; and surgical factors such as type of incision, suture type, and technique [4],[5],[6]. Such hernias can cause serious morbidity, such as incarceration in 6-15% [5],[7] and strangulation in 2% [7].

As a result of high recurrence rate in the repair of incisional hernia, various types of repairs have been used both anatomical and prosthetic. However, the results have been disappointing with a high incidence of recurrence of about 30-50% after anatomical repair [4] and 1.5-10% following prosthetic mesh repairs [5]. The introduction of prosthetics has revolutionized hernia surgery with the concept of tension-free repair. Although a wide variety of surgical procedures have been adopted for the repair of incisional hernia, the implantation of prosthetic mesh remains the most efficient method of dealing with incisional hernia [6]. The prosthetic mesh can be placed between the subcutaneous tissues of the abdominal wall and the anterior rectus sheath (onlay mesh repair) as well as in the preperitoneal plane created between the rectus muscle and posterior rectus sheath (sublay mesh repair). The later technique has several advantages, one of which being not transmitting the infection from subcutaneous tissues down to the mesh, as it lies quite deep in the preperitoneal plane [7].

  Materials and methods Top

Fifty-two patients with incisional hernia were admitted to Menoufiya University Hospital from July 2010 to February 2013. All patients were operated upon by the retromuscular mesh repair technique. Patients with inflamed, obstructed, or strangulated hernia were excluded from the study. The included patients were subjected to complete history taking and clinical examination and were prepared for elective surgery for hernia repair.

A prophylactic dose of antibiotic was given at induction of anesthesia. After incising the skin and subcutaneous tissue, the sac was dissected and delineated. Thereafter, the sac was opened, contents were reduced, and intra-abdominal adhesiolysis was performed. The defect in 35 patients was in midline incisional hernia, in four patients following right paramedian incision, in three patients after right Kocher incision, in five patients after Pfannenstiel incision, and in two patients after transverse umbilical incision.

A plane was created between the posterior rectus sheath and rectus muscle to place polypropylene mesh. The peritoneum and posterior rectus sheath was closed by 2/0 vicryl. Thereafter, the mesh was secured with interrupted 2/0 polypropylene sutures and then a suction drain was placed over the mesh.

The anterior rectus sheath and muscular aponeurosis were approximated or closed if possible in front of the mesh. Thereafter, the subcutaneous space was closed with interrupted absorbable sutures and the skin with polypropylene sutures. Intravenous antibiotics were given to all patients on the first day. More duration of antibiotic therapy was given only if infection had been encountered according to culture and sensitivity.

  Results Top

A total of 52 patients underwent retromuscular mesh repair of incisional hernia, 15 male patients (28.8%) and 37 female patients (71.2%). The age of the patients ranged from 20 to 61 years with a mean age of 45.4 ± 10 years [Table 1].
Table 1: Demographic data of the studied patients

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The main presenting complaint was a swelling in the vicinity of the previous operative scar (defect in 35 patients was in midline incisional hernia, in four patients following right paramedian incision, in three patients following left paramedian incision, in three patients after right Kocher incision, in five patients after Pfannenstiel incision, and in two patients after transverse umbilical incision) [Table 2].
Table 2: Scar distribution of previous operation in the studied patients

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The operative time ranged from 50 to 120 min with a mean of 84.88 ± 18.04 min. Patients had a period of drainage ranging from 2 to 5 days (mean = 3.1 ± 0.9 days). After removal of the drain, seroma did not occur in any of the studied patients. Wound infections occurred in three patients (5.7%) who were treated conservatively [Table 3]. Patients were followed up for a period ranging from 12 to 30 months with a median 21 months. No recurrence was encountered in the studied patients during the period of follow-up.
Table 3: Operative time and postoperative complications

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  Discussion Top

Historically, incisional hernias have been repaired with either primary suture techniques or placement of a variety of prosthetic materials. Before the 1960s, most ventral hernias were repaired primarily with suture and a few with metallic meshes. Even with some modifications, the recurrence rates with the primary suture repair ranged from 24 to 54%. The introduction of polypropylene mesh repair opened a new era of tension-free herniorrhaphy. The recurrence rates with prosthetic mesh decreased to 10-20%. Subsequently, it was realized that the placement and fixation of the mesh was more crucial in determining the outcome of the repair. Analysis of various techniques of incisional hernia repair along multiple outcome variables reveals that mesh-based repair offers the best alternative when compared with the suture-based technique [4],[8]. The main issue is increased risk for infection with the placement of a foreign body and the cost factor. Postoperative complications such as seroma formation, hematoma, cellulitis, and wound infection have been attributed largely to the extensive dissection and tissue handling during hernia repair. Repair with mesh requires longer operating time and has greater intraoperative blood loss. Both these factors have been reported to be associated with increased wound infection. The incidence of incisional hernia is highest among female patients in the fifth and sixth decades of life. Gynecological operations with a lower midline incision accounts for the majority of the index operations, which result in incisional hernia [9]. This coincides with our results in which most of the patients were female individuals after gynecological operations.

The placement of the mesh in the preperitoneal, retromuscular position with a wide overlap of at least 5 cm over the hernia defect in all directions was introduced in the late 1980s. The refinement of this method decreased the recurrence rates to as low as 3.5%, making it to be declared the standard of care of ventral hernias [10].

The fundamental principles of the open retromuscular (preperitoneal) repair described by Stoppa [11] and Rives [12]that entail placing the mesh in this plane have many advantages. This plane is highly vascular; hence, it prevents infection, and, moreover, any infection occurring in the subcutaneous plane does not affect the mesh, as the mesh is retromuscular in a deeper plane. This coincides with our results where infection in the studied patients was 5.7% with no seroma formation. The preperitoneal approach allows for an even distribution of forces along the surface area of the mesh. This accounts for the strength of the repair and the decreased recurrence associated with it. The repair capitalizes on the physics of Pascal's principle of hydrostatics using the forces that create the hernia defect to hold the mesh in place [13],[14],[15],[16]. The prosthesis adheres to the posterior rectus sheath and renders it inextensible, permitting no further herniation, no dislodgement or rupture by intra-abdominal pressure but instead is held in place by the force that caused the hernia. Finally, it is a virgin plane for recurrent incisional hernia repairs.

Seroma formation is one of the most commonly reported complications after ventral hernia repair [14],[17],[18]. It occurs immediately after operation in virtually all patients. Most seromas develop above the mesh and within the retained hernia sac [14]. The mean incidence of seroma in reported series at a range of 4-8 weeks is 11.4%. In the largest multi-institutional trial, seromas that were clinically apparent more than 8 weeks were considered a complication and occurred in 2.6% [13]. Regardless of whether they are aspirated under sterile conditions or allowed to resolve, they rarely cause long-term morbidity. Aspiration may increase the risk for mesh infection but is recommended if they enlarge or persist before they reach their extremes. In our study, seroma was not encountered in any of the studied patients.

In a multicenter series of 850 patients, the recurrence rate after a mean follow-up period of 20 months was 4.7% [13]. The average recurrent rates using the onlay approach are ~4.2%, although rates as high as 17% have been reported [19]. The critical technical points related with recurrence are inadequate mesh fixation particularly with sutures and prostheses that overlap the defect by less than 2-3 cm. Other factors associated with high recurrent rates include postoperative complications, previous repairs, missed hernias as in the 'Swiss cheese' defects, longer operating time, and obesity. In our study, 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 [4],[7],[9]. Our follow-up, therefore, is probably not long enough and should be extended for at least another year.

  Conclusion Top

Retromuscular mesh repair is a good and an ideal technique for the treatment of ventral incisional hernias; we advocate this method of incisional hernia repair as it is applicable to all sites of incisional hernia, the mesh is mostly hidden and anchored behind the rectus sheath, the complication rate is low, and there is a low recurrence rate.

  Acknowledgements Top

Conflicts of interest

None declared.[23]

  References Top

1.Da Silva AL, Petroianu A. Incisional hernias: factors influencing development. South Med J 1991; 84 :1500-1504.  Back to cited text no. 1
2. Shaikh NA, Shaikh NM. Comparative study of repair of incisional hernia. J Pak Med Assoc 1994; 44 :38-39.  Back to cited text no. 2
3. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993; 73 :557-570.  Back to cited text no. 3
4. Ahluwalia HS, Burger JP, Quinn TH. Anatomy of the anterior abdominal wall. Oper Tech Gen Surg 2004; 6 :147-155.  Back to cited text no. 4
5. Dubay DA, Wang X, Kuhn MA, Robson MC, Franz MG. The prevention of incisional hernia formation using a delayed-release polymer of basic fibroblast growth factor. Ann Surg 2004; 240 :179-186.  Back to cited text no. 5
6. Complication of abdominal surgery. WJS 2005; 29 :1608-1613.  Back to cited text no. 6
7. Buerger JW, Lange JF, Halm JA. Incisional hernia prevention. In: Schumpelick V, Nyhus LM, editors. Meshes: benefits and risk. Springer; 2004. 399-405.  Back to cited text no. 7
8. Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc 2002; 16 :1207-1213.  Back to cited text no. 8
9. Chevel JP. Classification of incisional hernia of the abdominal wall. In: Morales-Conde S, editor. Laparoscopic ventral hernia repair′. Barcelona-Springer; 2002. 65-72.  Back to cited text no. 9
10.Oh T, Hollands MJ, Langcake ME, Parasyn AD. Incisional hernia repair: a Retrospective review and early experience of laparoscopic repair. Surgery 2004; 74 :50-56.  Back to cited text no. 10
11.Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg 1989; 124 :485-488.  Back to cited text no. 11
12.Usher FC. Hernia repair with knitted polypropylene mesh. Surg Gynecol Obstet 1963; 117 :239-240.  Back to cited text no. 12
13.Chowbey PK, Khullar R, Mehrotra M, Sharma A, Soni V, Baijal M. Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias. J Minim Access Surg 2006; 2 :106-109.  Back to cited text no. 13
14.Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years′ experience with 850 consecutive hernias. Ann Surg 2003; 238 :391-400.  Back to cited text no. 14
15.Burger JW, Halm JA, Wijsmuller AR, ten Raa S, Jeekel J. Evaluation of new prosthetic meshes for ventral hernia repair. Surg Endosc 2006; 20 :1320-1325.  Back to cited text no. 15
16.Bhandarkar DS, Katara AN, Shah RS, Udwadia TE. Transabdominal preperitoneal repair of a port-site incisional hernia. J Laparoendosc Adv Surg Tech A 2005; 15 :60-62.  Back to cited text no. 16
17.Tarnoff M, Rosen M, Brody F. Planned totally extraperitoneal laparoscopic Spigelian hernia repair. Surg Endosc 2002; 16 :359.  Back to cited text no. 17
18.Earle D, Seymour N, Fellinger E, Perez A. Laparoscopic versus open incisional hernia repair: a single-institution analysis of hospital resource utilization for 884 consecutive cases. Surg Endosc 2006; 20 :71-75.  Back to cited text no. 18
19.Pierce RA, Spitler JA, Frisella MM, Matthews BD, Brunt LM. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc 2007; 21 :378-386.  Back to cited text no. 19
20.George CD, Ellis H. The results of incisional hernia repair: a twelve year review. Ann Roy Coll Surg Engl 1986; 68 :185-187.  Back to cited text no. 20
21.Bauer JJ, Harris MT, Gorfine SR, Kreel I. Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients. Hernia 2002; 6 :120-123.  Back to cited text no. 21
22.Ahmed D, Khan MJ. Use of mesh in the management of recurrent incisional hernias. Pak J Surg 1995; 11 :101-102.  Back to cited text no. 22
23.Bhat Mahabhaleshwar G, Somasundaram Santosh K. Preperitoneal mesh repair of incisional hernias: a seven-year retrospective study. Indian J Surg 2007; 6:95-98.  Back to cited text no. 23


  [Table 1], [Table 2], [Table 3]


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