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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 575-579

Shoelace darn repair versus mesh repair hernioplasty in treating midline abdominal incisional hernia


Department of General Surgery, Faculty of Medicine, Menoufia University, Al Minufiyah, Egypt

Date of Submission19-Aug-2015
Date of Acceptance22-Nov-2015
Date of Web Publication23-Jan-2017

Correspondence Address:
Ayman M Al-Ebiary
Department of General Surgery, Faculty of Medicine, Menoufia University, Al Minufiyah
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198714

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  Abstract 

Objective
The objective of this study was to compare the efficiency and safety between the use of shoelace darn repair and the use of mesh repair in the management of midline abdominal incisional hernia.
Background
Midline abdominal incisional hernia is a complication caused by surgical wounds after different surgical procedures. Management of midline abdominal incisional hernia is performed through different surgical approaches.
Patients and methods
This was a 1-year, prospective, randomized study including 40 patients with midline abdominal incisional hernia. The patients were divided into two equal groups - group I (20 patients) repaired by shoelace darn repair and group II (20 patients) repaired using a polypropylene mesh. Both groups were evaluated for incidence of infection, hematoma formation, seroma formation, and recurrence for 12 months.
Results
Wound hematoma was found in one patient (5%) from group I and in one patient from group II (5%); there were no statistically significant differences between the two groups with regard to hematoma (P = 0.987). Similarly, seroma was found in one patient (5%) from group I and in one patient from group II (5%); there were no statistically significant differences between the two groups with regard to seroma (P = 0.987). Three patients (15%) from group I had recurrence of hernia, whereas two from group II had recurrence of hernia (10%), and statistical analysis proved that there was no significant difference between the two groups with regard to hernial recurrence (P = 0.637). One patient (5%) from group I complained of postoperative chronic pain, whereas two from group II (10%) complained of postoperative pain, and statistical analysis proved that there was no significant difference between the two groups with regard to postoperative chronic pain (P = 0.553). Wound infection was found in one patient (5%) from group I and in three patients from group II (15%), and statistical analysis proved that there was no significant difference between the two groups with regard to wound infection (P = 0.602).
Conclusion
From the present study, we concluded that shoelace darn repair is a better option for managing midline abdominal incisional hernias.

Keywords: mesh repair, shoelace, ventral hernia


How to cite this article:
Kohla SM, El-Fol HA, El-Gammal AS, Al-Ebiary AM. Shoelace darn repair versus mesh repair hernioplasty in treating midline abdominal incisional hernia. Menoufia Med J 2016;29:575-9

How to cite this URL:
Kohla SM, El-Fol HA, El-Gammal AS, Al-Ebiary AM. Shoelace darn repair versus mesh repair hernioplasty in treating midline abdominal incisional hernia. Menoufia Med J [serial online] 2016 [cited 2020 Feb 17];29:575-9. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/575/198714


  Introduction Top


Midline abdominal 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 the abdominal wall following laparotomy [1],[2] . A midline abdominal 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 midline abdominal incisional hernia in the literature is 2-11% following all laparotomies [3] , and it is a source of morbidity and requires high healthcare costs [1] .

Polypropylene, a nonabsorbable, monofilament mesh, is an effective material for hernia repair. It has been used liberally for four decades. It shows mild reactivity, seems to be noncarcinogenic, and it retains its strength for indefinite periods of time. It is pliable, and gets well incorporated into adjacent tissues by connective tissue in-growth into the mesh's intersect. Experimental studies have shown that the mesh is well incorporated into the abdominal wall within 2 weeks of implantation [3] .

Abrahamson (1988) described the 'shoelace repair' involving two suture lines. The first involves the use of an undermined and reflected strip of the medial edge of each anterior rectus sheath to construct a new linea alba. The second passes to and fro between the remaining cut edges of the anterior rectus sheaths, substituting for the missing sheaths and lacing up the abdomen back to its normal contours [4],[5] .

The aim of the present study was to evaluate the use of shoelace repair versus mesh repair hernioplasty in the treatment of midline abdominal incisional hernias.


  Patients and methods Top


Patients with midline abdominal incisional hernia from the surgical outpatient clinic of Menoufia University Hospital and the outpatient clinic of Damanhour National Medical Institute were included in our study. The study was conducted on 40 patients complaining of ventral hernia.

Selection of cases

Patients were selected according to the following inclusion and exclusion criteria:

Exclusion criteria

  1. Patients below 18 or above 65 years of age
  2. Recurrent umbilical or paraumbilical hernia
  3. Patients with chronic diseases (chronic hepatic diseases, chronic renal diseases, and patients under chronic corticosteroid therapy or chemotherapy)
  4. Incarcerated hernia or emergency procedures
  5. Recurrent incisional hernia.


Patients were classified into two groups:

  • Group I : The shoelace group: 20 patients were treated with shoelace repair hernioplasty
  • Group II : The mesh repair (control) group: 20 patients were treated with mesh repair hernioplasty.


All patients were subjected to the following:

  1. Complete history analysis
  2. Clinical examination
  3. Routine laboratory investigation including complete blood count, liver functions tests, renal function tests (urea and creatinine), and fasting blood sugar tests
  4. Abdominal ultrasonography
  5. Other investigations according to patient condition.


A written informed consent was obtained from all patients.

Ethical considerations

All the patients were given full information about the operation that will be performed, its benefits, and any harm entailed. An oral consent was obtained from the patients who agreed to participate in this study.

Procedures

All patients of group I were subjected to the following:

Anesthesia

General endotracheal anesthesia with full muscle relaxation was administered.

Preoperative examination

The abdomen was thoroughly examined before the start of operation, and the defect, the scar, and the skin incision and flaps were marked with an indelible skin marking pen.

Disinfection

Patients were disinfected using povidone iodine 10%.

Operative procedure

An elliptical skin scar excision was made, and then the skin and subcutaneous tissues were dissected off the hernial sac, as well as off the anterior rectus sheath on both sides. Each anterior rectus sheath was incised 1-2 cm from its medial edge, and the incision was extended up and down the entire length of the hernial defect. The two medial strips were sutured together by a continuous no. 1 monofilament nylon (polyamide) loop. This created a new linea alba and returned the hernial sac and its content to the abdominal cavity; next, the gap remaining between the laterally cut edges of the anterior rectus sheaths was sutured using 2-3 no. 1 nylon loop, beginning at the top end and taking good bites of the anterior rectus sheath in a vertical manner 2 cm away from the lateral cut edges and incorporating the newly created linea alba, thus restoring the rectus sheaths and rectus muscles to their normal position. This nylon suture passed to and fro in front of the rectus muscles and through the new linea alba for the entire length of the hernial defect in a manner of a shoelace tightening a boot. Excess skin and subcutaneous tissue were excised. Finally, the wound was closed with vacuum drains.

All patients of group II were subjected to general endotracheal anesthesia with full muscle relaxation. The abdomen was thoroughly examined before the start of operation, and the defect, the scar, and the skin incision and flaps were marked with an indelible skin marking pen. The skin was disinfected using povidone iodine 10%. With an elliptical skin scar excision, the skin and subcutaneous tissue were dissected off the hernial sac, as well as off the anterior rectus sheath on both sides. After dealing with the hernial sac either by invagination if there were no adhesions or by excision of the excess scar tissue till the edge of the defect, the defect was closed followed by tailoring of the required mesh before applying it. Finally, the wound was closed with vacuum drains. After the operation, patients were assessed according to a visual analogue score.

Follow-up

Patients were followed-up for 6 months postoperatively for the following:

  1. Operative technique (difficulties, time of operation)
  2. Immediate postoperative findings (till stitch removal) for early postoperative complications such as infection or disruption
  3. Postoperative follow-up for a short postoperative period (at least 1 year) for complications such as recurrence, sinus, etc., and below 6 month for hematoma formation.


Statistical analysis

We used the independent Student t-test and the Mann-Whitney test to compare the two groups for qualitative data.


  Results Top


The mean operative time for group I was 104 ± 65.7 min, whereas for group II it was 126 ± 77.3 min, with no statistically significant difference between both groups with regard to operative time (P = 0.338) ([Table 1]).
Table 1 Operative data of both groups


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The mean amount of blood loss during the operative procedure in group I was 238 ± 125.37 ml, whereas in group II it was 417.55 ± 163.94 ml, with more blood loss in group II (P = 0.0042) ([Table 1]).

Seroma was found in one patient (5%) from group I and in another patient from group II (5%); statistical analysis proved that there was no difference between both groups with regard to seroma. The amount of fluid in the seromas was not sufficient for calculation and the number of cases with seroma was low; seromas were treated by conservative measures (P = 0.987) ([Table 2]).
Table 2 Postoperative complications in both groups


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Wound hematoma was found in one patient (5%) from group I and in another patient from group II (5%), with no significant difference between both groups with regard to hematoma (P = 0.987) ([Table 2]).

Wound infection was found in one patient (5%) from group I and in three patients from group II (15%) with no difference between both groups (P = 0.602) ([Table 2]).

The mean postoperative pain score (by visual pain score) for group I was 21 ± 1.92 and for group II it was 23.75 ± 2.34, with no significant difference between both groups (P = 0.214) ([Table 3]). Pain was treated with nonsteroidal, anti-inflammatory analgesics, which were used for a mean period of 2 ± 6 weeks postoperatively in group I and for 3 ± 7 weeks in group II with no significant difference between both groups regarding the duration of postoperative analgesia use (P = 0.2225) ([Table 3]).
Table 3 Postoperative pain in both groups


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The mean postoperative hospital stay for group I was 5 ± 1.45 days and it was 6.2 ± 1.77 days for group II with no significant difference between both groups (P = 0.6304) ([Table 4]).
Table 4 Duration of hospital stay (days) in both groups


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Three patients (15%) of group I had recurrence of hernia and two of group II had recurrence (10%); statistical analysis proved that there was no significant difference between both groups with regard to hernial recurrence (P = 0.637) ([Table 5]).
Table 5 Outcome in both groups


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One patient (5%) of group I complained of postoperative chronic pain and two patients of group II (10%) complained of postoperative pain; statistical analysis proved that there was no significant difference between both groups with regard to postoperative chronic pain (P = 0.553) ([Table 5]).


  Discussion Top


Midline abdominal incisional hernia is a very common problem encountered by surgeons. It represents a complication and/or morbidity of abdominal surgery. The cause of incisional hernia is multifactorial [6] .

In our study, the operative time in group I was 104 ± 65.7 min and in group II it was 126 ± 77.3 min; there was no significant difference between both groups regarding the length of operative time.

Our results are in agreement with Majid et al. [7] , who found an operative time of about 1.5 h (for shoelace repair) in patients of his group.

Canziani et al. [8] recorded an operative time of 120-240 min for the surgical procedure of hernioplasty, which is much longer than the recorded time in this study.

In addition, Santora and Roslyn (2011) found in their study that the average operative time was 134 min, ranging  between 40 and 280 min [3] .

In addition, Gurusamy and Samraj [9] reported that potential complications of incisional hernia surgery include hernia recurrence, infection, seromas, hematomas, adhesions, bowel obstruction, and erosion of the mesh into the bowel or urinary bladder.

Blood loss during the operative procedure in group I was 238 ± 125.37 ml and in group II it was 417.55 ± 163.94 ml, with a significant increase in group II; this may be due to excessive dissection as well as implanting the mesh (P = 0.0042) ([Table 1]).

There was no significant statistical difference between the two groups with regard to postoperative complications such as infection (5% in group I and 15% in group II), wound hematoma, or seroma formation, as well as overall complication incidence. These results are in agreement with Majid et al. [7] , who observed wound infection in only 3% of their group.

In addition, Canziani et al. [8] recorded postoperative wound infection in 10% and wound hematoma in 7.5% of their patients, which is in agreement with our study; however, they did not record seroma formation in their patients.

Furthermore, Orenstein and colleagues (2011) found no wound-related complications (infection, hematoma) or significant seroma formation in their study [3] .

In addition, Clarke [10] found no significant difference between the two groups of his study with regard to postoperative complications (chronic pain, recurrence, wound infection).


  Conclusion Top


From the present study, we concluded that shoelace darn repair is a better option for managing abdominal incisional hernias, especially in patients with small defects and when there is a contraindication for mesh repair.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
El-Santawy HMG, 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 :226-229.  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 N Am 1993; 73 :557-570.  Back to cited text no. 3
    
4.
Akkermans PWC. Incisional hernia. Risk factors, prevention and repair, Drukkerij Edauw and Johannissen Co., Scheveningen, Netherlands, pp 2000; 25-54  Back to cited text no. 4
    
5.
de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, et al. Repair of giant midline abdominal wall hernias: component separation technique' versus prosthetic repair. World J Surg 2007; 31 :756-763.  Back to cited text no. 5
    
6.
Özkan OF, Celik A, Koksal N, Altinli E, Ç´elik AS, Qaglayan K, et al. The effect of shoe-lace and propylene mesh repair on pregnancy in incisional hernia model. Anatol J Clin Investig 2012; 6 :174-180.  Back to cited text no. 6
    
7.
Majid TA, Yassen MM, Shakir WM. Shoelace darn repair of abdominal incisional hernias. Iraq Postgrad Med J 2007; 6 :198-202.  Back to cited text no. 7
    
8.
Canziani M, Frattini F, Cavalli M, Agrusti S, Somalvico F, Campanelli G. Sutureless mesh fibrin glue incisional hernia repair. Hernia 2009; 13 :625-629.  Back to cited text no. 8
    
9.
Gurusamy KS, Samraj K. Wound drains after incisional hernia repair. Cochrane Database Syst Rev CD 2010; 005570 :6.  Back to cited text no. 9
    
10.
Clarke MH. Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique. Am J Surg 2010; 200 :2-8.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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