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Incisional herniation represents a significant, and often underestimated, drawback to invasive abdominal surgery. With anything up to 20% of patients developing an incisional hernia at some stage postoperatively, the effects on those affected – poor cosmesis, social embarrassment, impaired quality of life – represent a major detriment to the nation's abdominal surgical population, even before the more obvious problems of pain, strangulation and skin erosion are considered. There will be no imminent shortage of patients requesting incisional hernia repair. But how should they be best served? As with other forms of hernia repair, the debate regarding suture versus mesh repair should probably be considered obsolete. But is laparoscopic surgery a reasonable alternative to open mesh repair, or even the preferred solution? Laparoscopic incisional hernia repair is clearly technically feasible, and its potential advantages – reduced postoperative pain, shorter hospital stay, increased patient satisfaction – are clearly enticing. Banerjea and Bhargava cite meta-analyses supporting the benefits of the laparoscopic route, although perhaps of interest is the relative lack of evidence for any significant reduction in recurrence rates. Kingsnorth argues that large and complex incisional hernias, especially those with loss of domain, can only be repaired using open surgery, with component separation techniques facilitating fascial closure and onlay mesh re-inforcement. Such hernias probably remain beyond the scope of laparoscopic surgery, but the optimal treatment for smaller hernias remains contentious. As with many other areas of healthcare, prevention – in the form of fewer open and more laparoscopic abdominal procedures – may be preferable to cure.
Michael Booth Consultant Upper Gastrointestinal Surgeon
Royal Berkshire Hospital, London Rd, Reading RG1 5AN, UK
E: michael.booth@royalberkshire.nhs.uk
Incisional hernias are a heterogeneous problem and different methods of repair may be indicated for specific defects or locations. Unique advantages of the open technique include the ability to treat loss of domain with the components separation and restoration of abdominal wall anatomy and function (Fig. 1). No technique is the ‘best’ solution, knowledge of a wide variety of surgical options applied by surgeons with different skills is the optimal solution.
Large incisional hernia with loss of domain, only suitable for open repair.
Most laparoscopic surgeons will not attempt repair of defects > 10 cm. Even in highly specialised units, laparoscopic management of incisional hernias > 15 cm is controversial with a high complication rate.1 Bigger hernias are better treated by open operation for reasons given below.
The choice of open technique is between the onlay (Chevrel, prefascial) or the sublay (retromuscular) method. A Cochrane review concluded that there was insufficient evidence to recommend which method gave the best results.2 The inlay technique where mesh is applied without fascial closure should be obsolete because components' separation allows fascial closure in almost all cases.
In Sweden, a survey revealed that 40% of surgeons were still using sutured repair.3 Those using mesh repair applied an open onlay technique in 54%, open sublay in 44% and 1% used laparoscopic repair or the inlay technique. Whether this represents current practice in the UK is unknown. Sutured repair results in recurrence rates 2–3 times greater than mesh repair and, except in exceptional circumstances such as gross contamination or removal of infected mesh, should no longer be used.
The open techniques (onlay, sublay and inlay)
The onlay technique was originally reported by Chevrel. In 257 cases using the adjuncts of fibrin glue and relaxing incisions in the anterior rectus sheath, he achieved low morbidity and a recurrence rate of 4.9%. Other centres have achieved similar results including patients with major hernias > 10 cm transverse diameter.4
Rives developed the sublay technique and reported 183 cases with good results, recurrence of 3.4% and acceptable morbidity. Recent advocates of the technique have claimed that sublay is the ideal position for the mesh, but have not provided evidence from randomised trials.5 The disadvantages of the sublay are that it is more technically challenging, requiring the opening of a large space behind the rectus muscles The first layer of abdominal closure is the posterior rectus sheath and peritoneum below the arcuate line, where potential contact between mesh and bowel is possible or peritoneal closure may be incomplete. The sublay method is only applicable to midline hernias and cannot be used in other locations which represent 20% of anterior abdominal wall incisional hernias.
The inlay technique bridges the fascial defect (similar to the approach with laparoscopic surgery) and is an inferior operation because it does not restore the anatomy and physiology of the anterior abdominal wall. The technique exposes the viscera to contact with mesh requiring an expensive double-layered mesh with an inner non-adhesive coating.
Pre-operative preparation
Patients with major abdominal wall hernias (> 10 cm) and particularly those with loss of domain, stomas, fistulas, chronic sinuses or previous mesh should receive computed tomography (CT) scan prior to surgery.6 This will accurately outline the abdominal wall defect, the contents of the sac, the position of previous mesh, seromas, sinus tracks and abscesses. In obese patients, pre-operative weight loss is essential to ensure the safety of anaesthesia, to reduce postoperative complications and reduce loss of domain.
Pre-operative progressive pneumoperitoneum maintained for an average of 9 days has been used in some centres. The method is simple and involves a puncture site in the left hypochondrium with daily insufflation of ambient air of 1000–4000 cc to a maximum intra-abdominal pressure of 15 mmHg according to patient tolerance. Successful hernioplasty is then feasible in the majority of patients. There has been a failure to adopt this procedure by most centres for reasons that are unknown.
Wound infection after incisional hernia repair with mesh can be catastrophic and antibiotic prophylaxis is essential. Deep-seated infection has a serious impact on quality of life and occurs in 1–2%. The only prospective, non-randomised study reported a reduction in infection rate of 50% in those who were receiving prophylaxis.7
Choice of mesh
There are no long-term clinical or experimental data to support the use of most mesh products presently in use. The only randomised trial comparing light-weight mesh with standard-weight mesh in open repair reported a 17% recurrence rate for light-weight and a 7% recurrence rate for standard-weight mesh.8 The seroma rate for light-weight mesh using the sublay method was 34%. Abdominal wall compliance was collected in 87 patients and showed no treatment differences between light-weight and standard-weight groups indicating that the concept of the ‘stiff man syndrome’ or problems with compliance with standard-weight mesh in open repair is a myth.9
The understanding of the indications for biological meshes is under development. There are limited clinical data and short-term follow-up. Currently, the main application is in an infected or potentially infected field where the high cost is offset by the potentially expensive complications of an infected prosthetic graft.
The problems of mesh shrinkage have been exaggerated by extrapolation from animal studies. In a clinical surveillance study of shrinkage of polypropylene mesh inserted by onlay or sublay technique, a reduction in the calculated area of the mesh stabilised at approximately 30% at 12 months. Therefore, a mesh of 10 × 10 cm (100 cm2) will reduce in size to approximately 8 × 8 cm (64 cm2, a 36% shrinkage in area) representing a reduction in width or overlap of 2 cm, which is still sufficient to prevent recurrence at the edges of the mesh. Therefore, for open repair with complete fascial closure, no more than 5 cm overlap or a 10 cm width mesh will be required.
Loss of domain
The components' separation or Ramirez technique is a simple procedure which detaches the external oblique from the rectus muscle allowing a 10-cm advancement into the mid-line on each side of the abdomen. This confers a spherical shape to the abdominal cavity and increases capacity allowing return of viscera without risk of abdominal compartment syndrome.10 This additional procedure is not available to the laparoscopic surgeon. Overall, this application is only required in approximately 5% of incisional hernias and such patients are probably better referred to specialists.11 Recurrence rates without mesh supplementing components' separation are high but can be reduced with supplementary mesh.12 A recently developed triple mesh technique covering the exposed gaps in the external oblique aponeurosis has reduced the recurrence rate after components' separation to about 5% (Fig. 2).5
Completed onlay repair with components' separation and ‘triple mesh’ technique.
Conclusions
Smaller incisional hernias with a transverse diameter < 10 cm can be repaired successfully by a laparoscopic approach if a suitably skilled surgeon is available, although an ugly scar may remain on the anterior abdominal wall. Major defects > 10 cm are best repaired by an open operation. The simplest and most versatile technique is the onlay method. Hernias with loss of domain can only be repaired by an open method supplemented by components' separation.
References
1.Ferrari GC, Missandri A, Sansonna F, Magistro G, Dilernia S, et al. Laparoscopic management of incisional hernia > 15 cm in diameter. Hernia. 2008;12:571–6. doi: 10.1007/s10029-008-0410-0. [DOI] [PubMed] [Google Scholar]
3.Israelsson LA, Smedberg S, Montgomery A, Nordin P, Spangen L. Incisional hernia repair in Sweden in 2002. Hernia. 2006;10:258–61. doi: 10.1007/s10029-006-0084-4. [DOI] [PubMed] [Google Scholar]
4.Kingsnorth AN, Shahid MK, Valliattu AJ, Hadden RA, Porter CS. Open onlay mesh repair for major abdominal wall hernias with selective use of components separation and fibrin sealant. World J Surg. 2008;32:26–30. doi: 10.1007/s00268-007-9287-9. [DOI] [PubMed] [Google Scholar]
5.Schumpelick V, Klinge U, Junge K, Stumpf M. Incisional abdominal hernia: the open mesh repair. Lang Arch Surg 2004. 389:313–8. doi: 10.1007/s00423-003-0352-z. [DOI] [PubMed] [Google Scholar]
6.Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003;362:1561–71. doi: 10.1016/S0140-6736(03)14746-0. [DOI] [PubMed] [Google Scholar]
7.Rios A, Rodriguez JM, Munitz V, Alcaraz P, Perez Flores D, Parrilla P. Antibiotic prophylaxis in incisional hernia repair using a prosthesis. Hernia. 2001;5:148–52. doi: 10.1007/s100290100026. [DOI] [PubMed] [Google Scholar]
8.Conze J, Kingsnorth AN, Flament JB, Simmermacher R, Artt G, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg. 2005;92:1488–93. doi: 10.1002/bjs.5208. [DOI] [PubMed] [Google Scholar]
9.Kingsnorth A. Improving outcomes in hernia repair by the use of light meshes. World J Surg. 2007;31:1523. doi: 10.1007/s00268-007-9075-6. [DOI] [PubMed] [Google Scholar]
10.Ramirez OM, Ruas E, Dellon AL. ‘Components separation’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86:519–26. doi: 10.1097/00006534-199009000-00023. [DOI] [PubMed] [Google Scholar]
11.Kingsnorth AN, Sivarajasingham N, Wong S, Butler M. Open mesh repair of incisional hernias with significant loss of domain. Ann R Coll Surg Engl. 2004;86:363–6. doi: 10.1308/147870804236. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, et al. Repair of giant midline abdominal wall hernias:‘components separation technique’ versus prosthetic repair, interim analysis of a randomized controlled trial. World J Surg. 2007;31:756–63. doi: 10.1007/s00268-006-0502-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Colorectal Surgery, King George Hospital, Barking, Havering and Redbridge Hospitals NHS Trust, Goodmayes, Essex, UK
✉
Correspondence to: Ayan Banerjea, c/o Aman Bhargava, Consultant Laparoscopic & Colorectal Surgeon, King George Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Barley Lane, Goodmayes, Essex IG3 8YB, UK E: ayanbanerjea@hotmail.com
In the UK, approximately 600,000 patients undergo surgery that requires an abdominal incision each year (HES Online, <http://hesonline.nhs.uk>). Large, prospective, case series with long follow-up have shown that 10–20% of patients undergoing abdominal surgery may subsequently develop an incisional hernia.1,2 Thus, each year, 60,000–120,000 patients might be expected to present with this condition. Although a proportion of patients may experience no symptoms, the majority will describe complaints ranging from poor cosmesis, through recurrent abdominal pain, to features of gastrointestinal obstruction or strangulation of the hernia.
In elderly or medically unfit patients, incisional hernias may be treated conservatively using hernia belts, trusses and other supports. However, all patients must be made aware of the potential risk of hernia enlargement and ‘penduloma’ formation – a massive overhanging hernia that is often beyond surgical repair. Patients must also be warned about incarceration (15%) and strangulation (2%) of the hernia, precipitating acute admission and emergency surgery. Emergency procedures for hernias more frequently involve bowel resection and carry significantly increased risk of morbidity and mortality. Obesity is a common risk factor for incisional hernia formation and is not a contra-indication to surgery. Patients with body mass index greater than 40 kg/m2 may undergo laparoscopic surgery safely and patients with co-morbidities affecting up to two systems may also be considered for surgical repair.
Surgery
As with all hernia surgery, the principal aim is to obliterate the defect in the abdominal wall with a sound, tension-free repair as this minimises the risk of recurrence. The best means of achieving this remains controversial. The traditional method of open suture repair carries high rates of recurrence and has generally been superseded by the use of prosthetic mesh. One large, randomised, control trial comparing the two open techniques in 200 patients confirmed the superiority of mesh repair but the recurrence rates for both were still unacceptably high at 43% for suture repair and 24% for mesh repair.3
Open repair of an incisional hernia with mesh involves re-opening the old incision to allow dissection and reduction of the hernia sac. The mesh may then be placed over the defect, onlay repair, or deep to it, sublay repair, and must overlap the defect by several centimetres to minimise the risk of recurrence. Numerous surgical techniques employing a variety of mesh technologies have been described. A recent Cochrane review of open surgical techniques (CD006438) failed to identify significant advantages of any particular surgical technique, mesh type or mesh position. Open surgery requires considerable soft tissue dissection. Large incisions and extensive dissection may result in considerable postoperative pain, ileus, wound haematoma and wound infection, all contributing to prolonged hospital stays, delayed return to normal activities and increased risk of deep venous thrombosis/pulmonary embolism.
Laparoscopic surgery
The laparoscopic approach to incisional hernia repair was first described in 1993 and has evolved considerably in recent years. The technique requires placement of three or more ports sited away from the hernia to allow adhesiolysis and reduction of the contents of the hernia sac, visualisation of the hernia defect and intraperitoneal placement of a mesh that overlaps the defect (by at least 3 cm) in all directions. The mesh is typically secured to the abdominal wall with sutures. Metal tacs, usually in two rings to form a ‘double crown’, or a combination of sutures and tacs may also be used. Increasing clinical experience of the technique and the development of new mesh technology has allayed early fears regarding unacceptably high rates of major complications such as bowel injury during dissection, mesh adherence or erosion into the bowel, and the need to convert to open surgery (see below).
Laparoscopy demonstrates multiple defects associated with hernia.
Advantages of laparoscopic incisional hernia repair
The advantages of the laparoscopic approach have been confirmed in several reports. In randomised controlled trials, patients undergoing laparoscopic incisional hernia repair experience less postoperative pain than those undergoing open surgery, return to normal activity sooner and report improved satisfaction with cosmesis.4–7 Meta-analyses have also shown that length of hospital stay is shorter by 2–3 days and carries lower complication rates.8–10 In fact, laparoscopic repair can often be successfully carried out in a day-case setting and rates of re-admission to hospital are lower after laparoscopic surgery.7 Larger case series reporting the results of experienced practitioners have demonstrated that surgery can be completed laparoscopically in > 96% of cases and recurrence rates are as low as 3%.11,12 The recurrence rate in less experienced hands ranges from 3–15% and studies have suggested that the laparoscopic approach is at least as good as, or better than, open surgery at preventing recurrence in the short-to-medium term.2,9 However, two of three meta-analyses have not demonstrated any difference in recurrence rates using the laparoscopic approach and studies with longer follow-up are awaited.8,10
A crucial advantage over open surgery is that laparoscopy allows reliable identification of all abdominal wall defects associated with a previous incision. Clinical examination is often misleading because multiple defects may be associated with a single incisional hernia. In our own series of 104 patients who have undergone laparoscopic repair, the mean number of defects per patient noted at the time of laparoscopy was 2.7 compared to 1.2 defects detected at clinical examination pre-operatively. This major technical advantage may underlie the lower rates of recurrence of the laparoscopic technique as all defects can be addressed at the time of surgery. By contrast, in open surgery, smaller defects away from the clinically significant site may be missed and then present as a site of recurrence at a later date.
The abdomen is insufflated with carbon dioxide (pneumoperitoneum) during laparoscopic repair and deflation of the abdominal cavity after mesh placement ensures that the repair is tension-free and less likely to fail. The mesh is introduced via a port and does not come into contact with the patient's skin. Additionally, old infected tissues are not re-opened and the mesh is sited away from the new incisions, thus helping to reduce the risk of mesh infection associated with open surgery.9
Risks and complications of the laparoscopic approach
The commonest complication of laparoscopic incisional hernia repair is seroma formation at the site of the hernia (10–50%). Multiple abdominal wall defects and a large defect area are recognised risk factors for seroma formation. The incidence of seroma can be reduced by the use of compression bandages or binders that can be worn by the patient for up to 10 days' postoperatively. The majority of seromas resolve naturally and require no treatment; those that persist or cause significant discomfort may be aspirated, but only 2–5% require intervention.
Postoperative pain immediately after surgery can be severe and is often related to the use of sutures or metal tacs (staples) to secure the mesh. The administration of opiate analgesia in the recovery room controls pain early in the postoperative period and subsequent use of regular oral analgesics allows early discharge in most patients. Pain may persist beyond the initial recovery period but rarely interferes with return to normal activities. The use of local anaesthetic infiltration at the site of tac placement has not been shown to reduce pain significantly. Recent developments (such as tissue glue) may allow avoidance of metal tacs and prevention of tac-related pain in the future. The rate of postoperative ileus development is 5% and delays discharge from hospital.8,9,11 The rate of major complications such as bowel or blood vessel injury has been low in large series (≤ 3%).11
Is it more expensive?
Perceived disadvantages of laparoscopic incisional hernia repair are longer operating times and the increased cost of equipment and expensive specialised mesh. In fact, several retrospective and prospective comparative studies have shown that the laparoscopic approach does not take longer in experienced hands.4,5,9 Although there is an increased initial outlay for laparoscopic surgery, this is offset by several compensatory factors. Faster recovery from laparoscopic surgery and lower re-admission rates reduces the costs of bed occupancy and lower recurrence rates might reduce the need for repeat surgery. Cost-benefit analysis has shown laparoscopic incisional hernia repair to be cost neutral when compared to open surgery, even without consideration of patient benefits such as early return to work.12
Conclusions
Laparoscopic incisional hernia repair has been shown to be safe and efficacious, with numerous advantages for the patient and health care providers when compared to open surgery. Increasing clinical experience and greater adoption of this approach by surgeons will improve the quality of data available to support its role as the ‘gold standard’ treatment for this commonly encountered problem.
Acknowledgments
Aman Bhargava demonstrates laparoscopic incisional hernia repair at workshops sponsored by Gore Medical. Ayan Banerjea has assisted at several such workshops.
References
1.Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985;72:70–1. doi: 10.1002/bjs.1800720127. [DOI] [PubMed] [Google Scholar]
2.Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002;89:534–45. doi: 10.1046/j.1365-2168.2002.02083.x. [DOI] [PubMed] [Google Scholar]
3.Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–8. doi: 10.1056/NEJM200008103430603. [DOI] [PubMed] [Google Scholar]
4.Navarra G, Musolino C, De Marco ML, Bartolotta M, Barbera A, Centorrino T. Retromuscular sutured incisional hernia repair: a randomized controlled trial to compare open and laparoscopic approach. Surg Laparosc Endosc Percutan Tech. 2007;17:86–90. doi: 10.1097/SLE.0b013e318030ca8b. [DOI] [PubMed] [Google Scholar]
5.Olmi S, Scaini A, Cesana GC, Erba L, Croce E. Laparoscopic versus open incisional hernia repair: an open randomized controlled study. Surg Endosc. 2007;21:555–9. doi: 10.1007/s00464-007-9229-5. [DOI] [PubMed] [Google Scholar]
6.Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006;20:1839–45. doi: 10.1007/s00464-006-0118-0. [DOI] [PubMed] [Google Scholar]
7.Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K. Long-term outcomes in laparoscopic vs open ventral hernia repair. Arch Surg. 2007;142:562–7. doi: 10.1001/archsurg.142.6.562. [DOI] [PubMed] [Google Scholar]
8.Sains PS, Tilney HS, Purkayastha S, Darzi AW, Athanasiou T, et al. Outcomes following laparoscopic versus open repair of incisional hernia. World J Surg. 2006;30:2056–64. doi: 10.1007/s00268-006-0026-4. [DOI] [PubMed] [Google Scholar]
9.Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis. Arch Surg. 2002;137:1161–5. doi: 10.1001/archsurg.137.10.1161. [DOI] [PubMed] [Google Scholar]
10.Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig MK. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197:64–72. doi: 10.1016/j.amjsurg.2007.12.051. [DOI] [PubMed] [Google Scholar]
11.Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190:645–50. doi: 10.1016/s1072-7515(00)00280-5. [DOI] [PubMed] [Google Scholar]
12.Earle D, Seymour N, Fellinger E, Perez A. Laparoscopic versus open incisional hernia repair: a single-institution analysis of hospital resource utilization for 884 consecutive cases. Surg Endosc. 2006;20:71–5. doi: 10.1007/s00464-005-0091-z. [DOI] [PubMed] [Google Scholar]
