Repair of midline incisional hernias using the Lazaro da Silva aponeuroplasty technique

STUDY AIM: The aim of this retrospective study was to assess Lazaro da Silva's rectus sheath aponeuroplasty technique for repair of midline incisional hernias situated above the arcuate line. PATIENTS AND METHOD: Twenty-six patients underwent surgical repair of a supraumbilical (n = 19) or periumbilical (n = 7) incisional hernia. Six patients had had repeated laparotomies and two of them had recurrent incisional hernia. There were 11 obese patients (42%). Muscle diastasis ranged from 4 to 20 centimeters (mean: 9.7 cm). Three overlapping aponeurotic and peritoneal layers were used. The peritoneal sac was partially or totally incorporated in the repair. RESULTS: There was one postoperative death at day 5 from acute pancreatitis in a patient with associated cholecystectomy. Postoperative complications occurred in six patients. There were 3 abdominal wall infections. Obesity was the main factor associated with operative complications (p = 0.03). Mean follow-up was 19.1 months. There were 2 recurrences, one of them related to an abdominal wall infection. CONCLUSION: The Lazaro da Silva aponeuroplasty technique compares favourably with alternative techniques using mesh implants. It is indicated for incisional hernias less than 20 centimeters wide, situated above the arcuate line.     

A simplified incision of the external oblique aponeurosis during the components separation technique for the repair of large incisional hernias

Incising the external oblique muscle aponeurosis is an important part of the components separation technique for the repair of large incisional hernias. Endoscopically assisted section has been suggested to prevent complications of extensive skin flap formation. We used a simplified method for incising the external oblique aponeurosis, using a modified Collin Hartmann retractor, in 14 patients for the repair of large incisional hernias. Eight women and 6 men, with a mean (± standard deviation) age of 61.9 ± 14.9 years, underwent surgery. The median transverse diameter of the defect was 8.6 ± 3.0 cm. No postoperative morbidity occurred except 1 case of skin necrosis. One patient had a recurrence. Sectioning the external oblique aponeurosis during the components separation method using the technique described is a simple, safe, and economic approach that can prevent the complications described after the original techniques.     

Component separation in the treatment of incisional hernias

Incisional hernia repair following open laparotomy or laparoscopic abdominal surgery is a significant challenge for the general surgeon. Primary suture closure results in high rates of recurrence, and permanent mesh reinforcement is not routinely used in contaminated surgical fields. The use of component separation to allow for low-tension, prosthetic-free incisional hernia repair has improved outcomes in these challenging surgical circumstances.     

Review of stoma site and midline incisional hernias after stoma reversal

Background

The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias.

Methods

A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done.

Results

Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%–33.9%) and for midline incisional hernias was 44.1% (range 8.7%–58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two.

Conclusion

Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.     

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.     

The treatment of large midline incisional hernias using a retromuscular prosthetic mesh (Stoppa-Rives technique)

Incisional hernia is a common problem after abdominal surgery. Many repair techniques with prosthetic meshes have been proposed but there is no general agreement as to the best choice. Our retrospective experience with 35 patients treated using a large polypropylene mesh placed beneath the rectus muscles and above the peritoneum (Stoppa-Rives technique) is reported. There was no operative mortality. Major postoperative complications occurred in 7 (20%) patients. Wound infection developed in 5 (14.2%) patients and in one case the mesh had to be removed. The recurrence rate was 2.8%. In conclusion, retrorectus preperitoneal mesh repair is an effective technique with a low recurrence rate and very few postoperative complications.     

Transposition of rectus muscles of abdomen and autodermoplasty in the treatment of major and huge recurrent postoperative middle hernias

Experience of treatment of patients with major and huge recurrent postoperative middle hernias is analyzed. Control group consisted of 131 patients who were operated with Yanov's combined methods of autodermoplasty. Specific complications in early postoperative period were seen at 18 (13.7%) patients, 1 (0.7%) patient died. In long-term period recurrence was diagnosed at 26 (55.3%) of 47 operated patients with major hernias. Original combined methods of hernioplasty for major and huge recurrent postoperative middle hernias have been developed. Sixty-two patients were operated with these methods, specific complications in early postoperative period were seen at 8 (12.9%) patients, 2 (3.2%) patients of them died. Recurrence in long-term period was diagnosed at 1 (1.7%) patient. It is concluded that combination of O.Ramirez surgery with autodermoplasty is high effective.     

Repair of large complex recurrent incisional hernias with retromuscular mesh and panniculectomy

BACKGROUND: Recurrent incisional hernia repair is associated with high recurrence and wound complication rates. METHODS: The clinical courses of patients who underwent recurrent incisional hernia repair via retromuscular mesh placement with concomitant panniculectomy at a university teaching hospital from 1999 to 2004 were reviewed retrospectively. Postoperative evaluation included a quality of life survey. RESULTS: Forty-seven patients (13 male, 34 female) with an average body mass index of 34.4 kg/m2, an average midline hernia defect of 31.4 cm, and at least 1 and on average 2.5 previous repair attempts underwent hernia repair. Wound infections occurred in 4 patients (8%) and seromas requiring aspiration occurred in 1 patient (2%). Four patients (8%) had re-recurrences of their hernias. All patients rated the postoperative appearance of their abdomen as at least satisfactory. CONCLUSIONS: Recurrent incisional hernia repair with a retromuscular mesh and panniculectomy has low recurrence and wound complication rates and excellent patient satisfaction.     

Repair of large midline incisional hernias with polypropylene mesh: Comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia — 25 women and 28 men, mean age 60.4 (range 28–94) — were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.     

Repair of large incisional hernias with multiple small relaxing incisions technique

We report our results in repairing wide incisional hernial defects without using any prosthetic synthetic material, but expanding rectus sheaths by multiple small, 8 to 10 mm, relaxing incisions. In this way, hernial defect becomes smaller and fascial flaps are sutured to each other in an overlapping manner. These relaxing incisions are filled with collagenous connective tissue, and consequently do not cause any abdominal wall weakness. This procedure was performed on 32 patients with hernial defect of 4 x 4 cm to 15 x 15 cm. Mean hospital stay was 6, 8 days. In the follow-up period ranging from 5 to 42 months, no patient presented recurrence of the hernia. Rectus diastasis occurred in one patient who had been operated five times previously. Wound complication such as infection, seroma, haematoma developed in 9 of the patients, and were successfully treated by wound drainage and administration of appropriate antibiotic therapy. The findings of this study led us to conclude that the technique can be used in the repair of incisional hernias as an alternative technique.     

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.     

A novel approach for the simultaneous repair of large midline incisional and parastomal hernias with biological mesh and retrorectus reconstruction

Introduction

Patients with concomitant large midline incisional and parastomal hernias present many unique challenges to the reconstructive surgeon.

Methods

We describe a novel approach of simultaneously repairing the midline incisional and parastomal defect, while prophylactically reinforcing the relocated stoma site with a retrorectus biological graft.

Results

During the study period, 9 men and 3 women with a mean age of 65 years, body mass index (BMI) 34 kg/m², and American Society of Anesthesiologists score (ASA) 3.1 underwent repair. Hernia defects averaged 338 cm². Seven patients had a myofascial advancement flap. Mean operative time was 277 minutes. Postoperative complications occurred in 4 patients (33%) and included superficial surgical site infection, transient renal failure, and deep venous thrombosis; in addition, 1 patient died suddenly on postoperative day 3. After a mean follow-up of 14 months, 2 patients have asymptomatic hernia recurrence.

Conclusions

The use of various advanced abdominal wall reconstructive techniques may offer an acceptable approach to repairing these challenging defects.     

Giant midline abdominal incisional herniae repair through combined retro-rectus mesh placement and components separation: experience from a single centre

Aims

Giant midline abdominal wall incisional herniae require repair/reconstruction to restore the structural and functional continuity of the anterior abdominal wall. We describe here our approach to these demanding cases through a combined retro-rectus mesh placement and components separation and their overall functional outcome.

Methods

A retrospective analysis of a prospectively collected data was carried out and 28 patients who underwent giant (≥15 cm) midline incisional hernia reconstruction were identified in a large district general hospital between 2007 and 2013 with a median follow-up of 34 (6–76) months.

Results

Demographic data of our series include age of 60 (median) (30–87) years with a M:F ratio of 12:16, length of symptomatic hernia 18 (median) (12–36) months, more than two previous laparotomies (15), bowel obstructive symptoms (7) and recurrent herniation (7). BMI recorded was 32 (median) (24–46) and ASA of II (median) (I–III). Co-morbidities included cardiac disease (6), diabetes (6), respiratory disease (4) and systemic immunocompromise (2). Operative and technical details showed operative duration to be 180 (median) min, cranio-caudal rectus sheath defect 21 (median) cm, transverse rectus sheath defect 15 (median) cm, cross-sectional area of fascial defect 300 (median) cm² and size of mesh 690 (median) cm². Seven (25 %) developed short-term post operative complications: grade I seromata all resolving spontaneously (5); grade II superficial wound infections (2). Twenty-five (89 %) were completely asymptomatic at 34 (median) months’ follow-up; 2 (7 %) reported mild pain, but not limiting any activity; 1 (4 %) described pain occasionally limiting activity. There was no clinical recurrence with one patient developing global bulging.

Conclusions

Our series is comparable to the literature in patient cohort demographics, co-morbidity and risk factor profile; however, we demonstrate an excellent intermediate term outcome with no clinical recurrence and an improvement in quality of life, through their ability to perform normal day to day activities.     

Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique

The current surgical literature has not clearly demonstrated an optimal technique for abdominal closure. Prospective randomized studies published between 1980 and 1998 were analyzed and the relevant data derived from those studies were pooled for statistical evaluation. The outcome variables of dehiscence, infection, hernia formation, suture sinus formation, and pain were studied and the probability of their occurrence in association with different techniques was calculated. In relation to the outcome features of dehiscence and infection no statistically significant difference was seen when absorbable suture material was compared with nonabsorbable material. In regard to the probability of hernia formation no statistically significant difference was seen when monofilament absorbable material was compared with nonabsorbable material. There was, however, a higher incidence of hernia formation when braided absorbable suture material was used. In addition there was a higher incidence of incision pain and suture sinus formation when nonabsorbable suture material was used. Absorbable monofilament suture material is superior to both absorbable braided and nonabsorbable suture for abdominal fascial closure. A continuous mass (all-layer) closure with absorbable monofilament suture material is the optimal technique for fascial closure after laparotomy.