Incisional hernia treatment with progressive pneumoperitoneum and retromuscular prosthetic hernioplasty

BACKGROUND AND AIM: Major incisional hernias of the abdominal wall often pose a serious surgical problem. The choice between simple suture repair and mesh repair remains uncertain. METHODS: Seventy-seven patients underwent surgery to repair large abdominal incisional hernias, i.e., with parietal defects of 10 cm or more, by retromuscular prosthetic hernioplasty between 1996 and 1999. All patients were treated preoperatively by progressive pneumoperitoneum and were followed up for 2-5 years (mean 38.3 months). RESULTS: Almost all patients tolerated the pneumoperitoneum; no postoperative death occurred. Six patients developed a subcutaneous infection but none of them required removal of the mesh. Two patients (2.6%) had recurrent incisional hernia. CONCLUSIONS: This study shows that pneumoperitoneum is useful in preparing patients for incisional hernioplasty. Retromuscular mesh repair represents an appropriate surgical procedure, particularly in view of its low rate of recurrence.     

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.     

Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients

Abstract Background. The use of prosthetic materials in tension-free incisional hernia repairs has diminished reherniation rates markedly; however, infection, intestinal fistulization, and seroma formation have been reported after repairs. Use of the Rives-Stoppa procedure for incisional hernia repair, in which the prosthesis is placed between the rectus abdominis muscle and the posterior sheath, may reduce occurrence of these problems. Methods and materials. Over a 6-year period 57 open abdominal wall incisional hernia repairs were performed using the Rives-Stoppa technique; 15 (26.3%) had previously undergone incisional hernia repair. The prosthetic materials used were polypropylene, expanded polytetrafluoroethylene (ePTFE), and ePTFE with perforations. The prosthesis size ranged from 8×8 cm to 20×28 cm (mean area 199.6 cm²). Follow-up consisted of an office visit 12 months postoperatively and at least one subsequent office visit or telephone interview; mean follow-up time was 34.9 months (range 11.7–81.9). Results. There were no hernia recurrences (except in one patient whose prosthesis was removed), gastrointestinal complications, fistulas, or deaths. Seromas occurred postoperatively in seven patients (12.3%). Two patients (3.5%) had wound infections that required removal of the prosthesis. Conclusions. In this series the Rives-Stoppa technique had excellent long-term results, with minimal morbidity, in patients with large primary or recurrent incisional hernias. The absence of serious complications and hernia recurrences in patients with grafts in place suggests that the Rives-Stoppa procedure is the repair of choice in such patients. Electronic Publication     

Porcine dermal collagen (Permacol) for abdominal wall reconstruction

OBJECTIVE: A review of Eisenhower Army Medical Center's experience using Permacol (Tissue Science Laboratories, Covington, Georgia) for the repair of abdominal wall defects. METHODS: Retrospective review of medical records of patients undergoing abdominal wall reconstruction with Permacol. RESULTS: From July 30, 2003 to February 12, 2005, 9 patients underwent repair of complicated fascial defects with Permacol. Indications for surgery included reoperative incisional hernia repair after removal of a infected mesh (3 patients), reconstruction of a fascial defect after resection of an abdominal wall tumor (2 patients), incisional hernia repair in a patient with a previous abdominal wall infection after a primary incisional hernia repair (1 patient), incisional hernia repair in a patient with an ostomy and an open midline wound (1 patient), emergent repair of incisional hernia with strangulated bowel and multiple intra-abdominal abscesses (1 patient), and excision of infected mesh and drainage of intra-abdominal abscess with synchronous repair of the abdominal wall defect (1 patient). At a median follow-up of 18.2 months, 1 recurrent hernia existed after intentional removal of the Permacol. This patient developed an abdominal wall abscess 7 months after hernia repair secondary to erosion from a suture. Overall, 1 patient developed exposure of the Permacol after a skin dehiscence. The wound was treated with local wound care, and the Permacol was salvaged. Despite the presence of contamination (wound classification II, III, or IV) in 5 of 9 patients (56%), no infectious complications occurred. CONCLUSION: Complex reconstruction of the abdominal wall can be associated with a high complication rate. Placement of a permanent prosthetic mesh in a contaminated field is associated with a high rate of wound infections and subsequent mesh removal. Permacol becomes incorporated by tissue ingrowth and neovascularization. Permacol is a safe and acceptable alternative to prosthetic mesh in the repair of complicated abdominal wall defects.     

Concurrent Gastric Bypass and Repair of Anterior Abdominal Wall Hernias

Background: Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair. Methods: All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed. Results: 12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 ± 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 ± 10.3 kg/m² (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 ± 13.4 cm². One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 ± 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs. Conclusion: Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.     

Surgical treatment of postoperative incisional hernias by intraperitoneal insertion of dacron mesh and an aponeurotic graft: a report on 250 cases.

BACKGROUND: The therapeutic problems of giant incisional hernias of the abdominal wall are often difficult to resolve. The technique of repair must make up for the loss of abdominal wall substance and reestablish the interplay of the abdominal musculature. The use of prosthetic materials complies with these 2 imperatives. HYPOTHESIS: The results of surgical treatment of postoperative incisional hernias by intraperitoneal insertion of Dacron mesh and an aponeurotic graft were evaluated. DESIGN AND SETTING: Retrospective study of 250 patients in a university hospital. RESULTS: Postoperative mortality was 0.8%. Five patients (2%) developed a subcutaneous infection that did not affect the prosthesis. Another 5 patients (2%) developed a deep-seated infection that necessitated removal of the mesh in 3 cases. Eight patients (3.2%) had recurrence of incisional hernia. CONCLUSION: This retrospective study shows that giant abdominal wall hernias can be efficiently treated by the intraperitoneal positioning of Dacron mesh and an aponeurotic graft.     

Laparoscopic incisional hernia repair as first therapeutic choice

AIM: Incisional hernias are one of the most frequent complications of open abdominal surgery. Historically, the best results have been obtained with the open rives-stoppa approach. This is done by fixing a large piece of prosthetic mesh behind the rectus muscle. Laparoscopic approach allows similar mesh placement with minimal dissection and lower recurrence rate compared to the open mesh repair. METHODS: Between October 2001 to September 2003, 75 consecutive patients were scheduled to undergo laparoscopic incisional hernia repair with ePTFE mesh (Gore-Tex Dualmesh Plus). Postoperative complications were recorded and analysed. RESULTS: Most were obese affected by multiple wall defects Conversion to open surgery was required in 1 case Postoperative complications occurred 13.3%. Recurrence occurred in one only case. CONCLUSIONS: The key to the success of this procedure is avoidance of complications. The laparoscopic approach is safe, effective and relatively complication-free option in the management of patients presenting with a first time or recurrent incisional hernia and recommended as the treatment of choice.     

Retromuskuläre Netzplastik in Deutschland

Since the onset of an incisional hernia is caused by the biological problem of forming stable scar tissue, the mesh techniques are now the methods of choice for incisional hernia repair. Polypropylene is the material most widely used for open mesh repair. New developments have led to low-weight, large-pore polypropylene prostheses, which have been adapted to the physiological requirements of the abdominal wall and permit a reliable tissue integration. These meshes make it possible for a scar net to form rather than a stiff scar plate, thus helping to avoid the complications encountered with the use of earlier meshes. The ideal position for the mesh seems to be the retromuscular underlay position, in which the force of abdominal pressure holds the prosthesis tightly against the deep surface of the muscles. The retromuscular underlay repair technique has yielded the lowest incidence rates for recurrence: around 10% even after long-term follow up. Analysis of the failures after open mesh repair suggests that inadequate size of the mesh with insufficient overlap at the edges is the main reason for recurrence. An overlap of at least 5–6 cm all round must therefore be considered mandatory for successful reinforcement of the abdominal wall. Open mesh repair, particularly with modern low-weight polypropylene meshes applied by the retromuscular underlay technique, offers excellent results in the treatment of incision hernias, even in long-term follow-up studies.     

补片修补腹壁切口疝的临床应用

目的探讨腹壁切口疝的治疗。方法回顾性分析150例腹壁切口疝患者的临床资料。（1）肌腱膜上补片置入手术（ONLAY）126例；（2）筋膜前（腹膜前）、肌下补片置入手术（SUBLAY）4例；（3）缺损处直接补片置入途径（INLAY）13例；（4）腹膜腔内补片置入术（Introperitonealsite）7例。结果平均年龄58．5岁，女性占52．5％。上腹部切口36％，下腹部切口占64％。全部采用合成材料修补。聚丙烯材料130例，聚四氟乙烯-聚丙烯双面材料16例，强生Proceed补片4例，开腹手术143例，腹腔镜手术7例。复发3例，手术复发率为2％。结论ONLAY手术安全可靠，复发率低，是可以接受的切口疝修补方法，避免伤口感染，防治腹内压升高，促进伤口愈合，保证缝合质量是预防切口疝关键。     

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.     

Surgical treatment of large incisional hernias by an intraperitoneal Dacron mesh and an aponeurotic graft

BACKGROUND: The therapeutic problems of giant incisional hernias of the abdominal wall are difficult to resolve. The technique of repair must make up for the loss of abdominal wall substance and reestablish the interplay of the abdominal musculature. The use of prosthetic materials complies with these two imperatives. The aim of this prospective study was to evaluate the results of surgical treatment of postoperative incisional hernias by intraperitoneal insertion of Dacron (DuPont) mesh and an aponeurotic graft. STUDY DESIGN: We prospectively studied 350 consecutive patients who were operated on for giant postoperative incisional hernia. RESULTS: Postoperative mortality was 0.6%. Seven patients (2%) developed subcutaneous infections that did not affect the prostheses. Another seven patients (2%) developed deep-seated infections that necessitated removal of the mesh in five cases. Eleven patients (3.1%) had recurrence of incisional hernia. CONCLUSIONS: This prospective study shows that the intraperitoneal positioning of Dacron mesh and an aponeurotic graft can efficiently treat giant abdominal wall hernias.     

Progressive fascial wound failure impairs subsequent abdominal wall repairs: a new animal model of incisional hernia formation

BACKGROUND: Fascial wound failure alters the phenotype of the abdominal wall. This study introduces a novel animal model of progressive failure of the ventral abdominal wall fascia, which generates large incisional hernias. MATERIAL AND METHODS: A mechanistic model of incisional hernia was compared with a model of acute myofascial defect hernia repair. Using biological tissue repair markers, tensiometric measurements and recurrent hernia rate, we measured the mechanism by which incisional hernias regenerate abdominal wall structure and function after mesh and suture herniorrhaphy. RESULTS: Recurrent incisional hernia formation was significantly increased after repairs of the hernia model, compared with the myofascial defect model (6/16 vs 0/16, P < .05). In the hernia model, there were significant decreases in the recovery of wound strength, energy, and extensibility before mechanical disruption, compared with the myofascial defect model. Unexpectedly, excision of fascial hernia wound edges did not significantly improve tissue repair outcomes in the hernia model group. CONCLUSIONS: Clinically accurate animal modeling can recreate the wound pathology expressed in mature incisional hernias. Progressive fascial wound failure decreases the fidelity of subsequent incisional hernia repair, compared with identically sized acute abdominal wall defect repairs. The mechanism appears to include decreased fascial wound strength and decreased tissue compliance after herniorrhaphy.     

The Analysis of Infection after Polypropylene Mesh Repair of Abdominal Wall Hernia

Aim The aim of the study was to evaluate the frequency of superficial and prosthetic mesh infection following polypropylene mesh repair of different abdominal wall hernia in individual patients and to analyze the manifestation, clinical process and outcomes in patients with prosthetic mesh infection. Methods This was a retrospective analysis of 375 patients with 423 implanted meshes for groin, femoral, umbilical, incisional and epigastric hernias, with a mean follow-up of 15 months (range: 3–73 months). Results The total superficial infection rate was 1.65% percnt;, and the rate of mesh infection was 0.94% percnt;. There were no statistically significant differences in prosthetic mesh infection between monofilament and multifilament meshes as well as between the different repair groups of hernias. The deep incisional surgical site infection after previous operation was established as a significant risk factor for prosthetic mesh infection in incisional hernia repair (P < 0.0001). Five cases of prosthetic mesh infection were presented and analyzed. Conclusions There is no correlation between the superficial and prosthetic mesh infection. There may be difficulties in determining mesh infection and to choose the right tactic. The reconvalescence in all patients with mesh infection was achieved only after removal of the infected mesh. An erratum to this article is available at .     

Laparoscopic incisional hernia repair: our experience and review of the literature

Incisional hernia after laparotomy closure continues to be an important postoperative complication. Historically, the best results have been obtained with the open Rives-Stoppa technique. This approach is done by fixing a prosthetic mesh behind the posterior fascia of the rectus muscle. The laparoscopic approach allows similar mesh placement with minimal dissection. In this study, we review the scientific literature and report our experience, describing the clinical outcome of patients who have undergone laparoscopic repair of ventral hernias. After describing the standard technique of laparoscopic insertion of a prosthesis, we reviewed the records of all our patients who underwent such a procedure from March 2004 to January 2006. A laparoscopic approach was attempted in all patients. The patients' demographic characteristics, operative details and outcomes were recorded. Of 55 patients scheduled to undergo laparoscopic incisional herniorrhaphy, conversion to an open procedure was necessary in 2/55 (3.6%). All the remaining 53 patients (31 men and 22 women; mean age 51.8 years) underwent laparoscopic repair of ventral hernias. The mean fascial defect size was 98.3 cm (range: 5-200 cm). In 52/53 patients (98%) a dual mesh was used. 40% of patients (22/53) had multiple wall defects. The mean operative time was 90 minutes (range: 32-190 minutes). The average hospital stay was 2.6 days (range: 1-16 days). 50/53 patients (94.3%) tolerated an oral diet 24 hours after the operation. 49/53 (92.4%) returned to normal working activity within two weeks. The percentage of complications amounted to 13% (7/55), with 5.6% (5/53) minor and 3.7% (2/55) major complications. In one patient it was necessary to remove the mesh 6 months after surgery because of pain. The recurrence rate of 5.6% confirms the permanence of the repair. The follow-up was 12 months for 44/53 patients and 6 months for 9/53 patients. The procedure for incisional hernia repair used in our study may be performed safely with low complication and recurrence rates and should be considered for the majority of incisional hernia repairs requiring a mesh prosthesis.     

Staged repair of massive incisional hernias with loss of abdominal domain: a novel approach

BACKGROUND: The management of massive ventral hernias with loss of intra-abdominal domain is a challenging surgical dilemma. We report a novel approach for repairing these extremely complicated hernias. METHODS: We retrospectively reviewed our experience with the staged resection of Gore Tex Dual mesh (WL Gore and Associates, Flagstaff, AZ) in the setting of massive abdominal wall defects. The initial stage involves reduction of the hernia and placement of a large sheet of Gore Tex Dual mesh secured to the fascial edges. Subsequent stages involve serial excision of the mesh until the fascia can be approximated in the midline without tension. Finally, the mesh is excised, and the fascia is reapproximated with component separation and AlloDerm (Lifecell Corporation, Branchburg, NJ) underlay. RESULTS: We have performed this procedure on 8 patients, with a mean age of 53 years (range 35-76). All patients had multiply recurrent ventral hernias with an average of 4.3 prior laparotomies (range 2-9). The fascial defect averaged 535 cm2 (300-884 cm2), and on average 6 serial operations were necessary to achieve fascial closure. The average length of stay was 36 days (range 9-90). One patient developed a postoperative wound infection requiring operative debridement, and 1 recurrence was identified during follow-up after an early wound complication. CONCLUSIONS: Serial Gore-Tex excision to facilitate primary fascial closure with AlloDerm sublay is an effective treatment for massive, incisional hernias with loss of abdominal domain and avoids the risks associated with long-term prosthetic fascial closures.     

Laparoscopic ventral hernia repair with extraperitoneal mesh: surgical technique and early results

Laparoscopic repair of ventral abdominal wall hernias involves intraperitoneal placement of a mesh, which may lead to adhesion formation and bowel fistulation. The first series of selected patients with ventral abdominal wall hernias treated laparoscopically by extraperitoneal placement of a polypropylene mesh is presented. Thirty-four patients (24 women and 10 men; median age, 52 years [range, 34-70]) were selected from among 122 patients undergoing laparoscopic ventral hernia repair. Of these patients, 18 had a primary ventral abdominal wall hernia and 16 had an incisional hernia. After reduction of sac contents and adhesiolysis intraperitoneally, a large flap of peritoneum (with extraperitoneal fat, fascia, and posterior rectus sheath where present) was raised to accommodate a suitably sized polypropylene mesh, which was then covered again with the peritoneal flap at the end of the procedure. Intraoperatively, apart from circumcision of the hernial sac at the neck, a total of 24 iatrogenic peritoneal tears occurred in 20 patients, mainly at the site of the previous scar. In two patients, it was observed that greater than 25% of the mesh was exposed after the procedure. The median (+/-SD) duration of hospitalization postoperatively was 1 day (+/-0.56). One patient's hernia recurred 4 months after surgery, and one patient's infected mesh was removed 8 months after surgery. Laparoscopic extraperitoneal placement of a mesh is feasible and appears to be an advance over laparoscopic intraperitoneal mesh placement for ventral abdominal wall hernias in selected patients. However, longer follow-up and controlled clinical trials will be necessary before any firm conclusions can be drawn.     

Nuttall technique: A method for subumbilical incisional hernia repair revised

Background Large ventral incisional hernias are frequently repaired either by open or by laparoscopic mesh technique. The technique recommended by Nuttall has been used for the repair of large subumbilical incisional hernias but has not been popularized. Materials and methods From 1991 to 2005, 21 patients, mean age 64.6 ± 13 (44–86) years, underwent repair of large subumbilical incisional hernia with the Nuttall technique by which the rectus muscles are detached from the symphysis pubis and transposed to the opposite side. The exerted tension is minimal to the underlying tissues, and no prosthetic material is required to reinforce the abdominal wall. Results Morbidity was recorded in five patients (23.8%). The median follow-up time was 84 months, and the recurrence rate was 4.8% (one patient). Conclusions Although a small number of patients have undergone repair with the Nuttall technique, the long-term results of the method seem to be encouraging for the repair of large subumbulical incisional hernias.     

Characterizing laparoscopic incisional hernia repair

INTRODUCTION: Laparoscopic repair of ventral and incisional hernias (LVIHRs) is feasible; however, many facets of this procedure remain poorly defined. The indications, essential technical features and postoperative management should be standardized to optimize outcomes and facilitate training in this promising approach to incisional hernia repair. METHODS: All patients referred to one surgeon at a tertiary care centre for LVIHR from 1999 to 2004 were analyzed. Patient records were analyzed and perioperative outcomes were documented. RESULTS: Of the 69 patients who were referred for management of incisional hernia, 64 underwent LVIHR. The mean age of patients selected for surgery was 61.4 years (28% of patients over age 70 years); their mean body mass index (BMI) was 32.8 kg/m2 and mean American Association of Anaesthetists (ASA) score was 2.5 (52% of patients had an ASA score equal to 3). The mean operating time was 130.7 minutes for a mean abdominal wall defect of 123.9 cm2 and a mean prosthetic mesh size of 344 cm2. Patients with recurrent incisional hernias and previous prosthetic mesh were the most challenging, with a mean BMI of 39 kg/m2, mean operating time of 191 minutes, mean defect of 224 cm2 and mean prosthetic mesh size of 508 cm2. One patient was converted to open surgery and, in 2 patients, small bowel injuries were repaired laparoscopically without adverse sequelae. The mean length of stay was 4.5 days (median 3.0 d). Postoperatively, 78% of patients developed seromas within the residual hernia sac. All seromas were managed nonoperatively; one-half resolved by 7 weeks, and larger seromas persisted for up to 24 weeks. There was an 18.7% rate of minor complications and a 3.1% rate of major complications (no deaths). After a mean follow-up of 7.7 months, 2 recurrent hernias (3.1%) were identified in patients with multiple previous open mesh repairs. CONCLUSION: Although LVIHR may be challenging, it has the potential to be considered a primary approach for most ventral and incisional hernias, regardless of patient status or hernia complexity.     

Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques

The use of prosthetic mesh has become the standard of care in the management of hernias because of its association with a low rate of recurrence. However, despite its use, recurrence rates of 1% have been reported in primary inguinal repair and rates as high as 15% with ventral hernia repair. When dealing with difficult recurrent hernias, the two-layer prosthetic repair technique is a good option. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is controversial due to the increased risk of infection. The same is true when hernia repairs are performed concurrently with potentially contaminated procedures such as cholecystectomy, appendectomy, or colectomy. The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair using a four ply mesh of porcine small intestine submucosa (Surgisis®, Cook Surgical, Bloomington, IN, USA) in a potentially infected field and a combination of polypropylene and ePTFE (Gore-Tex®, W.L. Gore and Associates, Flagstaff, AZ, USA) in a clean field. From September 2002 to January 2004, nine patients (three males and six females) underwent laparoscopic and open placement of surgisis mesh in a two layered fashion for either recurrent incisional or inguinal hernias in a contaminated field. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (incarcerated or strangulated bowel within the hernia), two procedures were performed in a contaminated field because of infected polypropylene mesh, and one was in a clean field. Mean patient age was 56.4 years. The average operating time was 156.8 min. Operative findings included seven incarcerated hernias (four incisional and three inguinal), one strangulated inguinal hernia, and one ventral defect after resection of an abdominal wall metastasis for a previous colon cancer resection. In two of the cases, there was an abscess of a previously placed polypropylene mesh. All procedures were completed with two layers of mesh (eight cases with surgisis and one with combination of polypropylene/ePTFE). Median follow up was 10 months. Complications included two seromas, one urinary tract infection, two cases of atelectasis and one prolonged ileus. There were no wound infections. The average postoperative length of stay was 7.8 days. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. The use of a new prosthetic device in infected or potentially infected fields, and the two-layered approach shows promising results. This is encouraging and provides an alternative approach for the management of difficult, recurrent hernias.