Incisional hernia following appendectomy. Surgical experience

Summary Appendectomy is a very frequent cause of incisional hernia. In this paper the rate of recurrence after the hernia repair by simple suture and mesh repair was studied. 17 lateral incisional hernias secondary to appendectomy were repaired over a 9 year period. Prosthetic repair was carried out in 9 cases and primary closure in the remaining 8 cases. All the patients were followed over a period that ranged from 1 to 8 years (mean 5.6 years). There was one recurrence, though 2 patients (11.7%) with mesh repair complained about abdominal pain during the first postoperative year. The study concludes that both techniques can be successfully implemented if the correct indications based on the extent of the defect and the clinical characteristics of the patient are respected.     

Incisional hernias in midline incisions: An eight-year follow up

Summary The aim of this study was to report the incidence of incisional hernias following midline laparotomy incisions after 12 months and after 8 years. 374 patients who underwent midline laparotomy between August 1989 and December 1990 were included. The wounds were closed with a continuous suture and the technique was monitored by the suture length to wound length ratio. The incidence of incisional hernia, defined as a palpable defect in the fascia or a protrusion beyond this level, was monitored at 12 months and after 8 years. Early wound dehiscence occurred in 3 patients (1%) and wound infection in 32 (9%). At the 12-month examination 58 (20%) incisional hernias were detected in 292 patients. After 8 years 142 patients were examined and 5 (3%) hernias were found. All hernias that caused inconvenience or required surgical repair were detected at 12 months follow-up. Most hernias appearing later have probably been overlooked at the first examination.     

Incisional intercostal hernia after a nephrectomy

The aim of the present case report is to present the diagnostic and therapeutic challenge of intercostal incisional hernia. We report on a female patient with leftsided intercostal incisional hernia between the eleventh and twelfth rib due to preceding lumbar incision for tumor nephrectomy. Because of its infrequence, diagnosis was established late although simple clinical examination and ultrasound investigation displayed the hernia. At laparotomy, a 5×5 cm² fascial defect with a colonic sliding hernia was found. Hernia repair using permanent mesh reinforcement in the retromuscular position is described. Abdominal incisional hernia in the intercostal region is rare and therefore easily overlooked. As with other incisional hernias, the hernia repair using mesh implantation in the retromuscular region is technically feasible and represents the treatment of choice.     

Factors affecting recurrence after incisional hernia repair

Incisional hernias occur primarily as a result of high tension and inadequate healing of a previous incision, the latter of which is frequently related to infection at the surgical site. Despite recent advances in operative techniques, the recurrence rate remains unacceptably high. To evaluate the impact of different predisposing factors for the recurrence of incisional hernia, we reviewed retrospectively the medical records of 297 patients who had undergone incisional herniorrhaphy (188 tissue repairs, 109 mesh repairs) in our hospital. Demographic data (age and gender), type of repair, body mass index, hernia size, presence of chronic illnesses and wound complications were evaluated in a univariate and multivariate manner analysis. The overall recurrence rate was 30.3%, with the recurrence rate in patients who underwent tissue repair being 39.4% and that in patients following prosthetic repair 14.6%. The recurrence rate was significantly influenced by type of repair, obesity, hernia size, wound healing disorders and some chronic comorbidities. We conclude that it is necessary to become familar with the risk factors for recurrence of incisional hernia in order to eliminate or decrease their effect on the positive outcome of incisional herniorrhaphy.     

Incisional hernia repair

Purpose: A retrospective clinical trial was conducted to compare laparoscopic incisional hernia repair (LIHR) and open traditional repair (OR). Demographics, perioperative data, results, and follow-up data were examined to determine whether there was any difference in outcome, recurrences, and costs. Methods: From January 2000 to June 2002, 42 consecutive, unselected patients who successfully underwent LIHR were matched with 49 consecutive, unselected patients who received OR during the same period. The operating room database, clinical files, and outpatient sheets were examined. Patient demographics, results, follow-up data, and costs were compared between the two groups. Results: Demographic characteristics, obesity, ASA status, type of hernia, concomitant surgery, urgencies, and incidences of previous repair were well matched between the two groups. Hernia defect was significantly larger in the OR group (122 cm²) than in the LIHR group (83 cm²; p = 0.0006). The operative times and the overall complications rates were similar, but wound infections were more common in the OR group (12% vs 0%; p = 0.04). The analgesic requirement was smaller (mean ketorolac injections, 2 vs 5; p < 0.0001; additional opiates, 0% vs 24%; p = 0.0006) and the hospital stay was shorter (5 vs 8 days; p < 0.0001) in the LIHR group. No recurrences were noted in the LIHR group, but there were three recurrences (6%) in the OR group (p = 0.30, not statistically significant). The cost of the prosthesis was higher for laparoscopic procedure, although the reduction in the hospital stay largely balanced the overall cost (p = 0.017). Conclusions: In this study, LIHR appeared to be as safe as OR. Despite the fact that LIHR raised the prosthesis-related costs, the findings showed that LIHR has clinical (less wound complications, shorter hospital stay, reduced pain) and financial advantages over OR. No financial support was provided by manufacturers or private institutions for completion of this study.     

比较腹腔镜腹腔内与开放腹膜前间隙补片置入术治疗腹壁切口疝的效果

目的比较腹腔镜腹腔内补片置入术(IPOM)与开放腹膜前间隙补片置入术(Sublay)治疗腹壁切口疝的效果。方法选取2016-01—2019-01间在郑州大学第一附属医院接受疝修补术治疗的76例腹壁切口疝患者,将36例行腹腔镜IPOM术的患者作为腔镜组。将40例行开放Sublay术的患者作为开放组。回顾性分析患者的临床资料。结果2组患者均成功完成手术。2组手术时间差异无统计学意义(P>0.05)。腔镜组术中出血量、术后肠蠕动恢复时间及住院时间均少于开放组,差异有统计学意义(P<0.05)。腔镜组术后近期疼痛发生率低于开放组,差异有统计学意义(P<0.05),其余并发症差异无统计学意义(P>0.05)。结论腹腔镜IPOM术具有创伤小、恢复快、疼痛轻、出血少、并发症少等优点,具有更广阔的应用前景。     

Simplified technique for incisional hernia repair with mesh prosthesis

This paper describes a simplified technique for the repair of incisional hernias. The previous scar is resected, and the peritoneal sac is carefully dissected until it is completely exposed. The sac is opened to liberate structures adherent to the sac or to the area immediately surrounding the defect. The peritoneum is closed and invaginated to form a sac bed underlying the entire extent of the defect, and the mesh is laid on this sac bed. The mesh is then fixed with "U" stitches, reinforcing these by inserting a second line from the edge of the defect to the mesh. Suture material used is polypropylene 1/0 or 2/0. This procedure has been carried out on 15 patients, and after 1 year of follow-up, there has been no recurrence of the hernia. Operating time was reduced, and the surgical technique was found to be easier. Placing a mesh prosthesis inside the hernia sac and fixing it to the abdominal wall with two lines of suturing simplifies the repair procedure, reduces operating time, and is effective in the repair of all incisional hernias. A study is required to compare this outcome with the different mesh repair techniques.     

Burst strength of laparoscopic and open hernia repair

Background: There are few reports of overall strength of laparoscopic and open incisional hernia repair. Methods: After anesthesia, a 2-inch circular defect was made in the abdominal wall of 28 female swine. Gore-Tex DualMesh Biomaterial (W. L. Gore & Associates, Flagstaff, AZ) was used for all repairs. Sixteen animals underwent open repair and 12 underwent laparoscopic repair. Burst strength was detected within 2 weeks and at 6 weeks by euthanizing the animals and insufflating the abdominal cavity with water while measuring the intraabdominal pressure until it could no longer be pressurized. Results: Three events occurred after insufflation: rupture around patch (R), dissection from insufflation or pressure monitoring sites (D), or rectal prolapse (P). Failure after open early repair occurred at 289 (range 219–388) mmHg with 7-R, 1-P and late 289 (196–343) mmHg with 1-R, 6-P. Failure after laparoscopic early repair occurred at 259 (191–388) mmHg with 4-R, 1-P, 1-D and late 291 (140–330) mmHg with 2-R, 1-P, 3-D. Late groups were less likely to rupture. Conclusion: Both hernia repairs are durable at early and late periods. Tissue ingrowth adds to repair strength. We could not show that one repair was stronger than the other. Nonetheless, laparoscopic repair tended to degrade by dissection, which was our highest pressure event.     

疝环充填式无张力疝修补术并发症原因分析及预防

目的 分析疝环充填式无张力腹股沟疝修补术并发症发生的原因.方法 总结2002年6月～2007年5月采用疝环充填式无张力疝修补术治疗腹股沟疝332例,分析其并发症的发生情况.结果 随访15～60个月,术后切口持续疼痛3例,术后复发1例,阴囊水肿16例,尿潴留20例.结论 术中仔细解剖是减少无张力疝修补并发症的关键.     

腹壁切口疝无张力修补术及围手术期处理

【摘要】 目的 总结采用人工材料无张力修补腹壁切口疝的临床经验和方法,探讨人工材料置于腹壁不同的层次对疗效的影响及围手术期处理。方法 回顾性分析90例腹壁切口疝的手术方法、 围手术期处理、术后并发症、引流的放置及随访结果。结果 90例患者疝补术后恢复顺利,无严重并发症, 无术后死亡。1例发生切口红肿伴脂肪液化,1例因脂肪液化再次复发。结论 采用人工材料行无张力疝修补是合适的治疗腹壁切口疝的方法,人工材料置于腹壁不同层次均可取得良好疗效,良好的围手术期处理是疗效的重要保证。     

Laparoscopic incisional hernia repair

Background Recent advances in laparoscopic surgery have made various abdominal surgeries possible. To avoid wound infection, mesh repair of abdominal incisional hernias is performed laparoscopically. Here we present a new procedure to fix mesh to the abdominal wall. Surgical technique Four anchoring sutures are made using a suture-grasping device; the additional transabdominal sutures are then made with a modified double-needle device. Additional circumferential fixation with tacks is not necessary. Conclusions This new mesh fixation method involves simple suturing techniques and is less time consuming than the conventional procedure.     

Postoperative pain after laparoscopic ventral hernia repair: a prospective comparison of sutures versus tacks.

BACKGROUND AND OBJECTIVES: Mesh fixation in laparoscopic ventral hernia repair typically involves the use of tacks, transabdominal permanent sutures, or both of these. We compared postoperative pain after repair with either of these 2 methods. METHODS: Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively enrolled in the study. They were sorted into 2 groups (1) those undergoing hernia repairs consisting primarily of transabdominal suture fixation and (2) those undergoing hernia repairs consisting primarily of tack fixation. The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively. RESULTS: From 2004 through 2005, 50 patients were enrolled in the study. Twenty-nine had hernia repair primarily with transabdominal sutures, and 21 had repair primarily with tacks. Both groups had similar average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. Both groups also had similar times to return to work and need for narcotic pain medication. CONCLUSIONS: Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar postoperative pain. The choice of either of these fixation methods during surgery should not be based on risk of postoperative pain.     

Use of histoacryl® for incisional hernia repair

Summary The use of fibrin glues for the closure of wounds in mesh repair of abdominal wall incisional hernias has been found to reduce the morbidity rate. However, the substances of this type derived from blood have the potential risk of virus transmission. The application of a nonbiologic adhesive would eliminate this risk, while offering the same advantages. We have performed a prospective study with the aim of analyzing results of the application of enbucrylate (Histoacryl ?, B. Braun Melsungen AG, Germany) between the muscle layers and subcutaneous tissue after incisional hernia repair with associated dermolipectomy, assessing local morbidity, mean hospital stay and need of wound care. The study included 42 patients divided into two groups, with and without enbucrylate, and results were compared between the groups. The two groups of patients were homogeneous with respect to their clinical data. The incisional hernia was at the midline in all cases, and was repaired using retromuscular prefascial polypropylene mesh in combination with dermolipectomy. Patients in the Histoacryl ? group developed less local morbidity (seromas, hematomas or abscesses) (p < 0.05), had a shorter mean hospital stay (p < o.o1) and required less wound care. We found that this approach improved the results of surgery for large eventrations when repaired by mesh placement and dermolipectomy and decreased global cost because morbidity and hospital stay were reduced.     

Technical consideration for subxiphoidal incisional hernia repair

Background The main principle of incisional hernia repair with mesh augmentation is a wide overlap of at least 5 cm in all directions. This is complicated when cartilaginous or osseous structures border the fascial defect, most notably at the xiphoid after sternotomy or in large proximal incisional hernias.Method We performed an anatomic investigation of this problematic area with its different structures and layers that form the retroxiphoidal space.Results and conclusion The posterior lamina of the rectus sheath inserts on the posterior side of the xiphoid. This lamina inhibits a sufficient mesh placement. By sharp dissection dorsal the xiphoid process, the posterior lamina of the rectus sheath can be detached. This way the retroxiphoidal space can be opened. Further development of this space can be made by blunt dissection. In some cases, with retroxiphoidal scar formation after sternotomy, a sharp dissection might be necessary. This enables a combined retromuscular-retroxiphoid mesh augmentation repair with a sufficient underlay of at least 5 cm, according to the principles of sublay technique.     

Laparoscopic repair of postoperative perineal hernia

Perineal hernia is an uncommon complication of abdominoperineal resection and pelvic exenteration. We present an alternative not previously described for the surgical repair of this type of hernia: laparoscopic repair of postoperative perineal hernia. Electronic Publication     

Long-term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and mesh repair

Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n=37). In 12 patients (11%) umbilical hernia repair was achieved with mesh implantation. Fourteen umbilical hernia recurrences were noted (13%); none had been repaired using mesh. No relationship was found between wound infection or obesity and umbilical hernia recurrence. In the light of these results it is necessary to re-evaluate our clinical “guidelines” on mesh placement in umbilical hernia repair: apparently not every umbilical fascial defect needs mesh repair. Research should focus on establishing risk factors for hernia recurrence.     

Comparison of PTFE,pericardium bovine and fascia lata for repair of incisional hernia in rat model,experimental study

Incisional hernia is a frequent complication of abdominal surgery developing in 11–20 % of patients undergoing an abdominal operation. Regarding morbidity and loss of manpower, incisional hernias continue to be a fundamental problem for surgeons. In this experimental study, three commonly used mesh materials (Goretex PTFE; Tutoplast Fascia lata; Tutopatch Pericardium bovine) were compared according to effectiveness, strength, adhesion formation, histological changes, and early complications. Three groups, each consisting of 14 rats, have been formed as group A: polytetrafluoroethylene (PTFE), group B: pericardium bovine and group C: fascia lata. Evaluations were achieved at the end of the first and second postoperative week, respectively. Adhesion formation, wound maturation, bursting pressure, and tensile strength were evaluated. No statistically significant difference regarding adhesion formation was observed between groups although adhesion formation was less significant in PTFE and pericardium bovine groups than in the fascia lata group. Bursting pressure and tensile strength values were significantly higher in PTFE group than in the fascia lata group (P <0.05). No statistically significant difference was observed between groups regarding wound maturation. In this experimental model, PTFE and pericardium bovine were found to be superior to fascia lata in abdominal wall repair. Electronic Publication     

腹腔镜下切口疝补片修补术的临床应用

目的 探讨腹腔镜下腹壁切口疝修补术的手术方法、安全性等问题。方法对2004年3月至2006年5月79例行腹腔镜下补片修补术治疗腹壁切口疝病人的临床资料进行分析。结果 78例（98．7％）手术成功，1例因腹腔内广泛粘连而中转开放修补。平均手术时间为88min，平均术后住院4．6d，18例（22．8％）病人术中发现有1个以上的隐匿性缺损。术后并发症：术后短期内修补区腹壁明显疼痛58例（73．4％）。腹壁缝合点较长时间疼痛6例（7．6％），浆液肿14例（17．7％），无手术死亡，1例术后出现肠瘘，经保守治疗好转，1例腰部切口疝的病人术后复发。结论 多数病人腹壁切口疝可以经腹腔镜行粘连松解及补片修补术，并可在术中发现其他隐性缺损，手术安全性较高。对腹腔内广泛粘连而影响操作器械进入及粘连分离者，应及时中转开腹手术。     

腹腔镜上腹部切口疝修补术45例临床应用

目的探讨腹腔镜上腹部切口疝修补术的方法改进与效果。方法回顾性分析我院自2008年8月至2013年7月完成的腹腔镜上腹部切口疝修补术45例的病例资料。结果本组45例患者,中转开腹手术2例。关闭缺损法腹腔镜切口疝修补术35例。手术时间45—190min,平均（105±34．6）min;术后24—48h下床活动;1～3d后肠排气。术后住院时间2～17d,平均（6．5±2．8）d。39例患者随访1～56个月,有1例复发,复发率为2．6％,未发现慢性疼痛性并发症。结论腹腔镜上腹部切口疝修补术微创、并发症的发生率低、具有良好的应用前景。     

Predictors of mesh explantation after incisional hernia repair

Background

Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known.

Methods

This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002.

Results

Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4–22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation.

Conclusions

Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.