Laparoscopic treatment of subxiphoid incisional hernias in cardiac transplant patients

BACKGROUND: Symptomatic subxiphoid incisional hernias present difficult surgical problems, especially in immuno-suppressed cardiac transplant patients. Here, we describe the laparoscopic repair of subxiphoid incisional hernias in patients with a history of cardiac transplantation. METHODS: Four patients with subxiphoid hernias who had previously undergone heart transplantation were identified from a prospective database. Each underwent a laparoscopic repair with mesh implantation. RESULTS: Three patients had a previous open repair. The mean age was 62.5 years, an average of 64.3 months after transplantation. At the time of surgery, all patients were immunosuppressed, and each had a subxiphoid, poststernotomy incisional hernia. Gore dual mesh was used in 2 patients, while Parietex mesh was used in 2. Mean operative time was 122 minutes, and all were completed laparoscopically. The mean length of stay was 6.5 days, and the mean defect size was 286.25 cm(2). There was a significant correlation between hernia size and length of stay (P=0.037). Postoperatively, one patient (25%) developed pulmonary edema, and 1 patient (25%) had a prolonged ileus. CONCLUSION: Symptomatic subxiphoid incisional hernias are a challenging surgical problem in patients with a history of sternotomy. Laparoscopic repair is safe and effective in immunosuppressed patients who have previously undergone cardiac transplantation.     

The feasibility of adopting laparoscopic incisional hernia repair in general surgery practice: early outcomes in an unselected series of patients

A laparoscopic approach to incisional hernia repair has been shown to be safe and effective in selected patients. We report our early outcomes following laparoscopic ventral/incisional hernia repair (LVHR) in an unselected series of patients encountered in general surgery practice. All patients referred with incisional hernia were offered a laparoscopic repair using prosthetic mesh. Patients were not excluded from laparoscopic approach on the basis of age, previous surgery, defect size, intraperitoneal mesh, body mass index (BMI), comorbidities, or abdominal wall stomas. We followed 28 consecutive patients who underwent LVHR (17 primary, 11 recurrent hernias). Laparoscopic repair was completed in 27 patients with a mean operative time of 141.6 +/- 11.9 minutes. There were no intraoperative complications. The mean size of the abdominal wall defects was 153.4 +/- 27.5 cm and the mean mesh size was 349.2 +/- 59.1 cm. The mean hospital stay was 3.7 +/- 0.3 days. Nine patients developed large wound seromas; all spontaneously resolved. Our experience suggests that LVHR is feasible as a primary approach to most incisional hernias encountered in general surgery practice.     

Repair of subxiphoid incisional hernias with Marlex mesh after median sternotomy

Median sternotomy is sometimes complicated by a bifid xiphoid process and an incisional (ventral) hernia in the subxiphoid region. Such hernias often recur after primary suture repair. We recently initiated the use of a polypropylene prosthetic mesh to primarily repair subxiphoid incisional hernias. This report details the results of using this material in 14 patients between January 1980 and December 1983. We also discuss the complex anatomy of the xiphoid region.     

Outcome of laparoscopic ventral hernia repair in correlation with obesity,type of hernia,and hernia size

BACKGROUND: The morbidity and overall recovery time of ventral hernia repair can vary significantly depending on the hernia type or size and on other factors, such as the body mass index (BMI). The purpose of our study was to investigate the effects of type of hernia, hernia size, and BMI on the outcome of laparoscopic ventral hernia repair. METHODS: Fifty patients who underwent laparoscopic ventral hernia repair were retrospectively reviewed and stratified according to hernia type (incisional, IVH/primary, PVH), hernia size, and BMI. These subgroups were compared in regard to operative time, resumption of diet, hospital stay, pain control, and complication rate. RESULTS: Laparoscopic IVH repair was associated with a longer operative time (143 vs. 98 minutes, p = .02) and length of stay (2.2 vs. 0.6 days, p = .03) than PVH repair. The narcotic requirements were higher in the IVH group, but the difference did not reach statistical significance. Larger hernias were associated with a longer operative time (p = .04) and increased narcotic requirement (p = .03). The morbidity of the laparoscopic repair was not significantly affected by the hernia type or size. The BMI did not significantly alter any of the parameters examined. CONCLUSIONS: Laparoscopic repair of incisional and larger hernias is a technically demanding procedure that requires a longer operative time. In contrast to PVH repair, laparoscopic IVH repair usually cannot be performed on an outpatient basis. Surgeons need not be discouraged from recommending the laparoscopic approach for patients with large IVHs or with severe obesity because the morbidity remains low.     

Subxiphoid incisional hernias after median sternotomy

Background Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias. Methods We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies. Results Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found. Conclusions The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.     

Laparoscopic ventral hernia repair: an initial institutional experience

BACKGROUND: Ventral and incisional hernias remain a problem for surgeons with reported recurrence rates of 25-50% for open repairs. Laparoscopic approaches offer several theoretical advantages over open repairs. MATERIALS AND METHODS: All patients undergoing a laparoscopic ventral hernia repair from April to December 2000 were prospectively entered in a database. Patients underwent repair with expanded polytetrafluoroethylene dual mesh. Full-thickness abdominal wall nonabsorbable sutures and 5-mm tacks were placed circumferentially. RESULTS: Of 32 patients, 15 underwent incisional repair, 13 had repair of a recurrent incisional hernia, and 4 had repair of a primary abdominal wall defect. Two procedures [2/32; 6.3%] were converted to open, one for loss of abdominal domain and one for neovascularization due to cirrhosis. There were two early recurrences [2/30; 6.7%]. Both of these failures occurred in patients with hernia defects extending to the inguinal ligament, preventing placement of full-thickness abdominal wall sutures inferiorly. Average operating time was 128 +/- 42 min (range 37-225 min). Average length of stay was 1.8 days [range 0-7 days]. There were no transfusion requirements or wound infections. One patient underwent a small bowel resection after completion of repair. One patient required drainage of a seroma 4 weeks after the procedure. CONCLUSIONS: Laparoscopic ventral hernia repair can be safely performed with an acceptable early recurrence rate, operative time, length of stay, and morbidity. Securing the mesh with full-thickness abdominal wall sutures in at least four quadrants remains a key factor in preventing early recurrence.     

应用合成补片修补腹壁切口疝的经验总结

目的:探讨腹壁切口疝病人的无张力手术治疗方法和疗效.方法:回顾性分析我院2000年7月至2008年6月间收治的215例应用合成补片修补腹壁切口疝病人的临床资料.结果:215例中101例采用IPOM方法,有1例复发,复发率0.99%;97例采用Stoppa方法,有3例复发,复发率3.09%;17例采用肌前修补法,有3例复发,复发率17.6%.在21例复发疝病人中,16例采用了IPOM方法,无再复发病例;5例采用了Stoppa方法,有1例再复发,复发率20%.结论:IPOM方法和Stoppa方法的手术适应症宽、复发率低.IPOM方法对于复发的切口疝病人有更好的治疗效果.术者的经验和方法的正确性对修补的成功均有重要意义.     

Long-Term Outcome of 254 Complex Incisional Hernia Repairs Using the Modified Rives-Stoppa Technique

Background Repair of complex incisional hernias poses a major challenge. Aim The aim of this study was to review the outcomes of the modified Rives-Stoppa repair of complex incisional hernias using a synthetic prosthesis. Methods We reviewed patients undergoing a modified Rives-Stoppa repair of complex incisional hernias from 1990 to 2003. Patients were followed through clinic visits and mailed questionnaires. Follow-up data were complete in all patients (mean 70 months, range 24–177 months), and 87% of patients completed a mailed questionnaire. Primary outcome included mortality, morbidity, and hernia recurrence. Secondary outcome measures were duration of hospital stay, long-term abdominal wall pain, and self-reported patient satisfaction. Results Altogether, 254 patients underwent a modified Rives-Stoppa repair. Among them, 60% had a significant co-morbidity, and 30% had one or more previously failed hernia repairs. Mortality was zero, and overall morbidity was 13% (wound infection 4%, prosthetic infection 3%, seroma/hematoma 4%). The overall hernia recurrence rate was 5%, including explantation of mesh because of infection. Wound/prosthetic infection was predictive for hernia recurrence (31% vs. 4%, p = 0.003). Among the respondents, 89% reported overall satisfaction with their repair. Conclusion The Rives-Stoppa repair of complex incisional hernias using synthetic prosthetic materials is safe with a low recurrence rate (5%) and high patient satisfaction. Postoperative wound infection is a risk factor for hernia recurrence. This work was presented in part at the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract during Digestive Disease Week, Los Angeles, CA, May 2006. The abstract was published in Gastroenterology 2006;130:A891.     

The Repair of Incisional Hernia Following Roux-en-Y Gastric Bypass—With or Without Concomitant Abdominoplasty?

Background  Incisional hernia, found in up to 25% of patients, is a typical complication of open bariatric surgery. Methods  Open Roux-en-Y gastric bypass (RYGB) was performed in 204 patients. They have been followed-up for at least 6 months. Thirty-two patients in whom incisional hernia was diagnosed were divided into two groups—they were scheduled for hernia repair or hernia repair with abdominoplasty. The surgery was performed, on average, 20 months after RYGB operation. Fourteen patients [mean body mass 86.4 kg, mean body mass index (BMI) 30.0 kg/m²] have had hernias repaired. The mean duration of hospital stay was 7.2 days. Hernia repair along with abdominoplasty was performed in 18 patients with mean body mass 89.4 kg and BMI 31.5 kg/m². The mean duration of hospital stay was 8.7 days. Results  Both examined groups were similar in body mass, BMI, age, and duration of hospital stay (p > 0.05), as well as gender distribution. The wound infection was diagnosed in six patients. Conclusion  The simultaneous abdominoplasty does not prolong the time of hospital stay of the patients undergoing incisional hernia repair. Infection is the most frequent complication of incisional hernia repair.     

Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitoneal Gore-Tex mesh: prospective study and review of the literature

BACKGROUND: Recurrence rates after repair of incisional and ventral hernias range from 18% to 52%. Prosthetic open repair has decreased this rate, but the wide fascial dissection it requires increases the complication rate. Laparoscopic repair is a safe and effective alternative. PATIENTS AND METHODS: A prospective study was performed including 86 patients (63 women and 23 men) with a mean age of 54 years (range 29-79 years) having incisional or ventral hernias who underwent laparoscopic repair in our institution between July 1994 and October 2001. The majority of the patients were obese with a mean body mass index of 31.7 kg/m2. The abdominal wall defect size ranged from 2 X 1 cm to 20 X 13 cm. In all cases, a Gore-Tex mesh (Dual Mesh, W.L. Gore & Associates, Flagstaff, AZ, USA) was used in sizes ranging from 10 X 15 cm to 20 X 30 cm. RESULTS: Nineteen repairs were performed for recurrent hernias (12 incisional and 7 ventral). The mean operative time was 110.3 minutes (range 50-240 minutes). There was one open conversion (1.2%), one intraoperative complication (1.2%), and no deaths. There were no wound or mesh infections. Immediate postoperative complications occurred in 9 patients (10.6%) and late complications occurred in 16 patients (18.8%). The average hospital stay was 4.8 days (range 2-19 days). During a mean follow-up of 37 months (range 6-73 months), there were 6 hernia recurrences (7%). CONCLUSION: Laparoscopic repair of incisional hernia and ventral hernia appears to be safe, especially with the use of Gore-Tex mesh, and is proving to be effective as it decreases pain, complications, hospital stay, and recurrences.     

Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience.

OBJECTIVE: The purpose of the study is to define those patient variables that contribute to morbidity and mortality of median sternotomy wound infection and the results of treatment by debridement and closure by muscle flaps. BACKGROUND: Infection of the median sternotomy wound after open heart surgery is a devastating complication associated with significant mortality. Twenty years ago, these wounds were treated with either open packing or antibiotic irrigation, with a mortality approaching 50% in some series. In 1975, the authors began treating these wounds with radical sternal debridement followed by closure using muscle or omental flaps. The mortality of sternal wound infection has dropped to < 10%. METHODS: The authors' total experience with 409 patients treated over 20 years is described in relation to flap choices, hospital days after sternal wound closure, and incidence rates of morbidity and mortality. One hundred eighty-six patients treated since January 1988 were studied to determine which patient variables had impact on rates of flap closure complications, recurrent sternal wound infection, or death. Variables included obesity, history of smoking, hypertension, diabetes, poststernotomy septicemia, internal mammary artery harvest, use of intra-aortic balloon pump, and perioperative myocardial infarction and were analyzed using chi square tests. Fisher's exact tests, and multivariable logistic regression analysis. RESULTS: The mortality rate over 20 years was 8.1% (33/49). Additional procedures for recurrent sternal wound infection were necessary in 5.1% of patients. Thirty-one patients (7.6%) required treatment for hematoma, and 11 patients (2.7%) required hernia repair. Among patients treated since 1988, variables strongly associated with mortality were septicemia (p < 0.00001), perioperative myocardial infarction (p = 0.006), and intra-aortic balloon pump (p = 0.0168). Factors associated with wound closure complications were intra-aortic balloon pump (p = 0.0287), hypertension (p = 0.0335), and history of smoking (p = 0.0741). Factors associated with recurrent infection were history of sternotomy (p = 0.008) and patients treated for sternal wound infection from 1988 to 1992 (p = 0.024). Mean hospital stay after sternal wound reconstruction declined from 18.6 days (1988-1992) to 12.4 days (1993-1996) (p = 0.005). To clarify management decisions of these difficult cases, a classification of sternal wound infection is presented. CONCLUSIONS: Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.     

Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese

INTRODUCTION: Complex ventral incisional hernias (VIH) in the morbidly obese remain a difficult management problem for the general surgeon. Multiple methods of repair with variable rates of success are described. The outcomes and techniques of a fascial component separation technique with synthetic mesh reinforcement in the morbidly obese are described. METHODS: Records of patients undergoing VIH repair between June 1996 and May 2007 who had a body mass index (BMI) greater than 30 kg/m(2) were reviewed from a prospectively maintained database. Patient demographics, BMI, hernia characteristics, perioperative and long-term complications, and long-term hernia recurrence rate were documented. RESULTS: A total of 90 patients (22 men and 68 women) meeting study criteria were identified. The mean age was 55 years (range 30-82 years). Mean BMI was 39.9 (range 30-68). Recurrent hernias were present in 43 patients (48%) Mean number of recurrences was 1.5 (range 1-5). A total of 42 patients (47%) had multiple fascial defects. Major perioperative morbidity was 8% and perioperative mortality was 1.1%. Postoperative wound infections occurred in 9 patients (10%). Hernia recurrence was observed in 5 patients (5.5%) with a mean follow-up of 50 months (range 1-132). CONCLUSIONS: Fascial component separation can be performed with acceptable perioperative morbidity and mortality. Rates of wound sepsis, mesh infection, mesh explantation and gastrointestinal mesh erosion are low. Operative time, hospital length of stay, and long-term VIH recurrence are also acceptably low. Fascial component separation is a viable technique for repair of complex VIH in the morbidly obese population.     

Omental pedicle grafting in the treatment of postcardiotomy sternotomy infection

Postcardiotomy sternal infection occurred in 20 (2%) of 1007 patients undergoing cardiac surgery between September 1985 and December 1987, a 10-fold increase over the preceding 33 months (4 [0.24%] of 1627 patients). Cultures were sterile in 5 patients and yielded staphylococci in 12 and a variety of bowel organisms in 3. The cause for the increased occurrence of sternal wound infection is unclear after multivariate analysis, although infections have precipitously dropped subsequent to changing to cefuroxime sodium antibiotic prophylaxis. Treatment has evolved to appropriate antibiotics and early débridement of involved sternum and cartilage. Rewiring the sternum is not attempted. If gross purulence is not present, primary closure is accomplished using muscle flaps (2 patients) or omental pedicle grafts (17 patients). In the presence of gross purulence, the wound is packed open for 5 days and then closed in the above fashion. Two patients required skin grafts for primary closure. The omental pedicle flap is preferred due to simplicity and improved coverage of the sternal defect inferiorly. Nineteen patients healed primarily. A superficial wound infection was drained in 1 patient. Midline incisional hernias developed in 3 muscular patients. Omentum is now harvested through a left subcostal incision. Hospital stay was under 2 weeks in 13 patients. One death occurred due to multisystem failure prior to completion of wound closure. In our experience, early sternal débridement and omental pedicle grafting with primary closure is appropriate therapy for postcardiotomy sternotomy infections. The presence of gross purulence may require 5 days of open packing prior to omental grafting. No significant complications occurred, and mortality was low. A left subcostal incision for omental harvesting is utilized to avoid the occurrence of delayed incisional hernias.     

A prospective study of bilateral inguinal hernia repair.

A prospective study of outcome after inguinal hernia repair in patients undergoing simultaneous repair of bilateral hernias (n = 31), sequential repair of bilateral hernias (n = 5), and unilateral hernia repair (n = 75) is reported. There were no differences in wound complications, post-operative respiratory complications, or other adverse effects in the three groups. Operating time was similar in the unilateral and bilateral simultaneous repairs (median 55 min), but was longer (100 min) for the combination of two sequential repairs. Hospital stay was shortest for patients undergoing unilateral repair (2 days) but was less with bilateral simultaneous repair (4 days) than after two sequential repairs (total of 6 days). There were 12 (11%) wound complications of which five (5%) were infections. There was no difference in complication rate between unilateral and bilateral hernia repair. Postoperative recovery was assessed prospectively and was recorded at 1 month. There was no difference between unilateral and bilateral simultaneous repairs in the number of days before the patient was able to climb stairs easily, drive a car or return to work. The duration of the requirement for analgesia was similar in each group. We conclude that bilateral simultaneous hernia repair can be carried out with no greater morbidity than a unilateral repair, and the return to normal activity is as rapid. Bilateral hernias should be repaired simultaneously rather than sequentially.     

Components separation technique and laparoscopic approach: a review of two evolving strategies for ventral hernia repair

When faced with large ventral hernias, surgeons frequently must choose between higher incidence of recurrence after primary repair and higher incidence of wound complications after repair with mesh. The aim of this study is to compare early outcomes between laparoscopic repair (LR) and components separation technique (CST), two evolving strategies for the management of large ventral hernias. We reviewed 42 consecutive patients who underwent CST and 45 consecutive patients who underwent LR of ventral hernia defects of at least 12 cm2. Demographics, hernia characteristics, and short-term outcomes were compared between groups. Patients in the LR group were younger (53 +/- 2 vs 68 +/- 2 years, P < 0.0001), had greater body mass index (34 +/- 2 vs 29 +/- 1 kg/m2, P = 0.02), and had larger hernia defects (318 +/- 49 vs 101 +/- 16 cm2, P < 0.0001) than patients in the CST group. The LR resulted in shorter length of hospital stay (4.9 +/- 0.9 vs 9.6 +/- 1.8 days, P < 0.0001), lower incidence of ileus (7% vs 48%, P < 0.0001), and lower incidence of wound complications (2% vs 33%, P < 0.001) than the CST. Both techniques resulted in similar operative times, transfusion requirements, and mortality. Recurrences occurred in 7 per cent of patients at mean follow-up of 16 months in the CST group and 0 per cent at mean follow-up of 9 months after LR. The LR may have a short-term advantage over the CST in terms of incidence of ileus, wound complications, and hospital stay. Because of their unique advantage over traditional hernia repairs, both techniques may play a significant role in the future treatment of large ventral hernias. Adequate training will be essential for the safe and effective implementation of these techniques within the surgical community.     

Ventral Hernia Repair in Bariatric Surgery

Background: Obesity is an important risk factor for perioperative complications including the development of ventral hernias. Methods: This retrospective study comprises patients who underwent abdominal hernia repair simultaneously with or following implantation of a Swedish Adjustable Gastric Band? (SAGB). Results: 9 out of 415 patients (2.2%) who received a SAGB between January 1996 and June 2001 underwent ventral hernia repair. In 6 patients, hernias preexisted from previous abdominal surgery at the time of the bariatric procedure, and another 3 hernias occurred at the median and left upper abdominal trocar position following SAGB placement. Median BMI at time of SAGB implantation was 44 (range 35-52), and at time of hernia repair was 36 (range 25-46). 2 hernias were repaired during SAGB placement, 3 during redo surgery, and 2 during abdominoplasty. In 2 patients, significant weight loss with loss of soft tissue support of the hernia sac led to recurrent episodes of small bowel obstruction necessitating emergency repair. Repair included direct defect closure in 7 patients and sublay polypropylene net implantation in 2 patients. Recoveries have been uneventful without wound infections or recurrence in all patients after a median follow-up of 34 months (range 13-69). Conclusion: In morbidly obese patients, the optimal management and timing of incisional hernia repair should weigh the risk of recurrence and perioperative complications against the risk of hernia-associated complications.     

Successful closure of abdominal wall hernias using the components separation technique

The "components separation" technique involves separating the layers of the abdominal wall to allow midline advancement. The purpose of the study was to compare the success rate of the components repair versus other methods. Repair methods included components separation (n = 11), mesh (n = 15), primary (n = 21), TFL grafts (n = 5), TFL or latissimus flaps (n = 4), and rectus turnover (n = 4). The results were: 16 of 60 hernias recurred, with significant risk factors being body mass index (BMI) greater than 30 kg/m2 (p = 0.04), wound infection or breakdown (p < 0.03), and possibly concurrent colostomy or enterocutaneous fistula repair (p = 0.11). Only one of 11 hernias recurred using the components methods, four of 15 recurred using mesh repairs, three of 21 recurred using primary repairs, four of five recurred using TFL grafts, two of four recurred using TFL/latissimus flaps, and two of four recurred using rectus turnovers. There were 19 complications (infection or wound breakdown), with risk factors being smoking (p = 0.002) and possibly BMI greater than 30 kg/m2 (p = 0.08). The results suggest that the components separation method is a viable option for repair of complex abdominal wall hernias without the use of distant flaps or grafts.     

Abnormal collagen I to III distribution in the skin of patients with incisional hernia

The surgical mesh-free repair of incisional hernias has to face recurrence rates of up to 50%. Apart from technical faults this is probably due to collagen metabolic disorders, known to play an important role in the development of inguinal hernia. In particular an altered ratio of collagen types I and III with an increase in collagen type III has been claimed to reduce the mechanical strength of connective tissues. Therefore, we investigated the content of collagen types I and III in the skin of patients with incisional hernia (n = 7) and recurrent incisional hernia (n = 5) in comparison to controls with healthy skin (n = 7) and normal skin scar (n = 7) both by immunohistochemistry and Western blot analysis. Both immunohistochemistry and Western blot analysis revealed a decrease in the ratio of collagen I/III due to a concomitant increase in collagen III. The patients with incisional hernias and with recurrent incisional hernias showed a ratio of 1.0 +/- 0.1 and 0.8 +/- 0.1, respectively, whereas the controls exhibit a ratio of 2.1 +/- 0.2 in healthy skin and of 1.2 +/- 0.2 in normal skin scar, respectively. The decrease was highly significant (p < 0.01) between the patients with either primary or recurrent hernia and the controls or the normal scar, as well as between controls and normal scar, whereas there was not any significant difference between primary and recurrent hernia (p > 0.05). Our data for the first time confirmed that the presence of incisional hernia is accompanied by impaired collagen synthesis in the skin. The decreased tensile strength of collagen type III may play a key role in the development of incisional hernias. Furthermore, it might explain the high recurrence rates of hernia repair by simple closure, as a repetition of the primarily failing technique, and the improvement by the additional use of alloplastic material.     

Abnormal primary tissue collagen composition in the skin of recurrent incisional hernia patients

Recurrence of incisional hernia may be as high as 50 per cent. Abnormal collagen I/III ratios have been observed within scar tissue of patients with recurrent incisional hernias. We sought to determine whether collagen composition in primary, nonscarred tissue was similarly affected in these patients. In this prospective, case-control study, nonscarred, primary abdominal wall skin and fascia biopsies were obtained in 12 patients with a history of recurrent incisional hernias and 11 control subjects without any history of hernia while undergoing abdominal laparoscopic surgery. Tissue protein expression of collagen I and III was assessed by immunohistochemistry followed by densitometry analysis. The collagen I/III ratio in skin biopsies from the recurrent hernia group was significantly less compared with control subjects (0.88 +/- 0.01 versus 0.98 +/- 0.04, respectively, P < 0.05). Fascia biopsies from patients with recurrent hernias was not significantly decreased in collagen I/III ratio compared with control subjects (0.90 +/- 0.04 versus 0.94 +/- 0.03, respectively, P = 0.17). Decreased collagen I/III ratios within the skin of patients with recurrent hernias not involved with scar or healing tissue suggest an underlying collagen composition defect. Such a primary collagen defect, in addition to abnormal scar formation, likely plays a significant role in the pathogenesis of recurrent incisional hernias.