Incisional hernia | Hernia information leaflet | Home

Mr H. S. Khaira     MD, FRCS      Consultant Surgeon

Mr P. Lall              FRCS            Senior House Officer

Miss B. Hunter      FRCS            Senior House Officer

Mr J. H. Brown      FRCSEd        Associate Specialist

ABSTRACT

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, gynaecological in 8, hepatopancreaticobiliary in 3, aortic aneurysm repair in 2 and involved a thoraco-laparotomy in 3. The incisions were midline in 26, transverse in 6, paramedian in 2 and roof top in 1. The hernias were considered subjectively to be large in 15, medium in 14 and small in 6. A proforma was completed for each patient noting intra-operative and post-operative complications, post-operative hospital stay and analgesic requirements.

There were no intra-operative complications. Post-operative complications included seroma formation in 6 patients, deep vein thrombosis in 1 and a non-fatal pulmonary embolism in 1. One patient developed a wound haematoma and 1 had a superficial wound infection. Post-operative in-hospital stay ranged from 1 to 27 days with a mean of 6.2 days. Post-operative analgesia requirements accorded to subjective size of hernia. 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 1 (3%) reported persistent pain but none of the 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.

INTRODUCTION

Incisional hernias develop in 3.8 – 11.5 % of cases 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 infection¹. Ninety percent of incisional hernias occur within 3 years of operation².

Repair of large abdominal incisional hernias is a difficult surgical problem with recurrence being a common complication. 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 1 or 2 layers or Mayo-type overlap^3,5-9, use of fascia (local or flaps) with suture darns^10,11, and the use of fascia with synthetic mesh (polypropylene or Marlex mesh^12-17, stainless steel¹⁸, mersilene¹⁹ or expanded polytetrafluoroethylene²⁰). In a literature review Loh et al¹¹ state that overlapping techniques produce impressive results and that techniques combining fascia with mesh have the advantage of overcoming excessive tension.

We describe our experience with a technique using fascia and polypropylene mesh originally described by Browse and Hurst¹². This technique was initially used in the repair of long midline incisional hernias but subsequently applied to subcostal hernias by Whiteley et al¹⁷. Our modification involves the introduction of an overlap and 2 points of anchor for the mesh.

METHOD AND PATIENTS

METHOD: 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 3 doses of intravenous cefuroxime (750mg). The drains were removed when less than 50ml drained in 24 hours. Post-operatively the patients were mobilised as soon as possible and discharged home once independent and drains had been removed.

PATIENTS: Thirty-five consecutive patients are described (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, gynaecological in 8, hepatopancreaticobiliary in 3, aortic aneurysm repair in 2 and involved a thoraco-laparotomy in 3. The original incisions were midline in 26, transverse in 6, paramedian in 2 and roof top in 1. The size of the incisional hernia was subjectively considered to be large in 15, medium in 14 and small in 6. Six patients had had a previous attempt at hernia repair. A proforma was completed for each patient noting intra-operative and post-operative 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 (1 dose of diclofenac sodium was 100mg, 1 dose of co-proxamol was 2 tablets and 1 dose of morphine was 10mg intramuscular injection). Follow-up data was compiled from clinic visits and telephone survey.

RESULTS

There were no intra-operative complications but 1 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 1 patient requiring repeat aspirations and 1 requiring excision of a seroma cavity 5 months later. Despite full prophylaxis 1 patient developed a deep vein thrombosis and another had a non-fatal pulmonary embolism. The 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).

Post-operative analgesia requirements according to subjective size of hernia are shown in table 2. It can be seen that the larger hernias required more opiate analgesia with 4 patients requiring a continuous background infusion of morphine in the form of PCA (patient controlled analgesia) for 1 day only and 1 patient requiring an epidural for 3 days. PCA was commenced electively in these 4 patients.

In all patients the wound healed without problems. 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 (6.1%) patients reported a persistent lump and 1 (3.0%) reported persistent pain but none of the 33 was found to have a recurrence.

DISCUSSION

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 2 points of fixation⁴, mesh placed deep to the rectus sheath with overlap and mattress suture fixation¹³, a complex "mesh-peritoneal sandwich"¹⁴, fixation of a large mesh anterior to the rectus sheath with 2 points of fixation¹⁵, and a combination of fascia and mesh^12,17. It has been suggested that overlapping leads to a better repair when one considers using fascia alone²¹ or in combination with mesh^{4,13-15,19,20}. Langer and Christiansen 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 recurrence³. Loh et al¹¹ 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 mesh. Liakakos et al¹⁶ 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. Their patients were not, however, 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 2 points of fixation. This method has been used for hernias arising from incisions other than midline¹⁷.

Wound infection is a potentially major complication which, fortunately, is usually superficial but can be severe enough to necessitate removal of the mesh¹⁴.

Matapurkar et al¹⁴ reported no seroma formation because their mesh was incorporated into a peritoneal sandwich. Formation of seroma was reported at 4% by Molloy et al¹⁵, 6% by Lewis²² and 5.8% by Usher²³ despite the subcutaneous position of the mesh and the extensive dissection involved. Jacobs et al²⁴ reported a 45% seroma rate whether suction drains were used or not. 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 reports a 1.6% incidence of seroma formation after inguinal hernia repair with a mesh and suggests this lower rate is due to the deeper position of the mesh²³.

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^3,4 and 80-90% develop within 3 years^2,4. One could argue, therefore, that our follow-up is 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.

Thus 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 2 points of fixation, there is relatively little pain allowing for early mobilisation, the complication rate is low and there is a low recurrence rate.

REFERENCES

1. Bucknell TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. BMJ 1982; 284: 931-933.

2. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985; 72: 70-71.

3. Langer S, Christiansen J. Long-term results after incisional hernia repair. Acta Chir Scand 1985; 151: 217-219.

4. Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg 1989; 124: 485-488.

5. Young D. Repair of epigastric incisional hernia. Br J Surg 1961; 48: 514-516.

6. Maguire J, Young D. Repair of epigastric incisional hernia. Br J Surg 1976; 63: 125-127.

7. Jenkins TPN. Incisional hernia repair: a mechanical approach. Br J Surg 1980; 67: 335-336.

8. Van Der Linden FTPM, Van Vroonhoven ThJMV. Long-term results after surgical correction of incisional hernia. Netherlands Journal of Surgery 1988; 40-5: 127-129.

9. Manninen MJ, Lavonius M, Perhoniemi VJ. Results of incisional hernia repair. A retrospective study of 172 unselected hernioplasties. Eur J Surg 1991; 157: 29-31.

10. Hunter RR. Anatomical repair of midline incisional hernia. Br J Surg 1971; 58: 888-891.

11. Loh A, Rajkumar JS, South LM. Anatomical repair of large incisional hernias. Ann R Coll Surg Engl 1992; 74: 100-105.

12. Browse NL, Hurst P. Repair of long, large midline incisional hernias using reflected flaps of anterior rectus sheath reinforced with marlex mesh. Am J Surg 1979; 138: 738-739.

13. Usher FC. New technique for repairing incisional hernias with marlex mesh. Am J Surg 1979; 138: 740-741.

14. Matapurkar BG, Gupta AK, Agarwal AK. A new technique of "Marlex – Peritoneal Sandwich" in the repair of large incisonal hernias. World J Surg 1991; 15: 768-770.

15. Molloy RG, Moran KT, Waldron RP, Brady MP, Kirwan WO. Massive incisional hernia: abdominal wall replacement with Marlex mesh. Br J Surg 1991; 78: 242-244.

16. Liakakos T, Karanikas I, Panagiotidis H, Dendrinos S. Use of Marlex mesh in the repair of recurrent incisional hernia. Br J Surg 1994; 81: 248-249.

17. Whiteley MS, Ray-Chaudhuri SB, Galland RB. Combined fascia and mesh closure of large incisional hernias. J R Coll Surg Edinb 1998; 43: 29-30.

18. Validire J, Imbaud P, Dutet D, Duron JJ. Large abdominal incisional hernias: repair by fascial approximation reinforced with a stainless steel mesh. Br J Surg 1986; 73: 8-10.

19. Adolff M, Arnaud J-P. Surgical management of large incisional hernias by an intraperitoneal Mersilene mesh and aponeurotic graft. Surg Gynecol Obstet 1987; 165: 204-206.

20. Van der Lei B, Bleichrodt RP, Simmermacher RKJ, van Schilgraffe R. Expanded polytetrafluoroethylene patch for the repair of large abdominal wall defects. Br J Surg 1989; 76: 803-805.

21. Hope PG, Carter SStC, Kilby JO. The Da Silva method of incisional hernia repair. Br J Surg 1985; 72: 569-570.

22. Lewis RT. Knitted polypropylene (marlex) mesh in the repair of incisional hernias. Can J Surg 1984; 27: 155-157.

23. Usher FC. Hernia repair with marlex mesh. An analysis of 541 cases. Arch Surg 1962; 84: 73-76.

24. Jacobs E, Blaisdell FW, Hall AD. Use of knitted Marlex Mesh in the Repair of ventral hernias. Am J Surg 1965; 110: 897-902.

Incisional hernia | Hernia information leaflet | Home

Table 1: Post-operative complications occurring in 35 patients.

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Table 2: Post-operative analgesia requirements. The median number of doses and the ranges are given. PCA = patient controlled analgesia, EPI = epidural analgesia.

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Figure 1: Diagrammatic representation of the incisional hernia.

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Figure 2: The medial leaf of the divided rectus sheath is dissected free and reflected medially.

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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.

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Figure 4: A sheet of marlex mesh is sutured to the undersurface of the lateral rectus sheath.

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Figure 5: The lateral leaf of the rectus sheath is sutured to the mesh.

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