Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 69, Num. 3, 2007, pp. 95-98

Indian Journal of Surgery, Vol. 69, No. 3, May-June, 2007, pp. 95-98

Original Article

Preperitoneal mesh repair of incisional hernias: A seven-year retrospective study

Bhat MahabhaleshwarG, Somasundaram SantoshK

Department of Laparoscopy Surgery, Wockhardt Hospital, Bannergatta Road, Bangalore - 560076
Correspondence Address:Unit 102, I Floor, Prestige Towers, 99/100 Residency Road, Bangalore - 560 025, Karnataka
drmgbhat@gmail.com

Code Number: is07031

Abstract

Keywords: Incisional hernia, mesh repair, preperitoneal repair

Incisional hernia occurs through an operative scar. It is the only hernia considered to be iatrogenic. It occurs due to the failure of the lines of closure of the abdominal wall following laparotomy. An incisional hernia occurs when all the layers except the skin, fail to heal.

Incisional hernia is one of the most common conditions requiring major surgery. The reported incidence in literature is 2-11% following all laparotomies. ^[1]

Various types of repair have been described, both anatomical and prosthetic. But the results have been disappointing with a high incidence of recurrence-about 30-50% after an anatomical repair and 1.5-10% following prosthetic mesh repairs.

The present study aims at evaluating our technique of preperitoneal mesh repair of incisional hernias that is being practiced in our surgical unit.

Materials and Methods

A seven-year retrospective study of preperitoneal mesh repairs was done from January 1994 to December 2000. In all, 105 preperitoneal mesh repairs were done. The data and details of 95 (90.5%) patients were collected from operation registers and medical records. A computerized database was created for all these patients. For follow-up, a self-addressed response card was sent containing a questionnaire. Patients were either requested to attend the outpatients department (OPD) personally for follow-up or mail back the response card after answering the questionnaire, if they could not attend the OPD. A few of the patients who could not do either were questioned over the phone and the results of repair or complaints, if any, were recorded. Sixty-five patients attended our follow-up. Details were entered in our database and results statistically analyzed.

Our technique involves the placement of a permanent prosthetic mesh (polypropylene) in a preperitoneal plane. After incising the subcutaneous tissue, the sac is dissected and delineated. The defect, most often in the midline, is opened along the linea alba. A plane is created between the posterior rectus sheath and the rectus muscle for the placement of the mesh. The posterior rectus sheath along with the peritoneum is closed with continuous 1/0 polypropylene sutures. A polypropylene mesh cut to size is placed in the plane created. The mesh is secured with a few interrupted 3/0 polypropylene sutures. A suction drain is placed over the mesh. The anterior rectus sheath is closed with continuous 1/0 polypropylene sutures. Another suction drain is placed in the subcutaneous plane and the skin closed. The sheaths are lax and redundant due to the hernia and associated weakness. Due care is required not to excise any of the redundant tissue until final closure of the tissues. This will ensure good availability of the layers to close without any tension at the end. The peritoneum, posterior rectus sheath and anterior rectus sheath sometimes become short for closure. This is usually due to early excision of the sac / sheath during dissection. We have used a separate mesh to close the peritoneum to prevent tension in four cases [Figure - 1].

The advantages of placing the mesh in this plane is as follows:

1. This plane is highly vascular, hence, it prevents infection.
2. Any infection occurring in the subcutaneous plane does not affect the mesh, as the mesh is retromuscular in a deeper plane.
3. The prosthesis adheres to the posterior rectus sheath and renders it inextensible, permitting no further herniation.
4. The prosthesis unites and consolidates the anterior abdominal wall.
5. The prosthesis in this plane cannot be dislodged or ruptured by intraabdominal pressure, but instead is held in place by the very force that caused the hernia.
6. Usually a virgin plane for recurrent incisional hernia repairs.
7. Tension-free repair.

Results

Age and sex

One hundred and five patients underwent preperitoneal mesh repair of incisional hernia during the seven-year study described in this report. The youngest patient was 29 years old and the oldest was 75 years old. The average age of incidence of the hernia was 45.51 ± 10.77 years. Females (90.5%, n =90) outnumbered males (9.5%, n = 10) and the highest incidence amongst them was in the 5 ^th decade of life.

Age at presentation among the males (52.60 ± 10.8 years) was greater than in the females (44.77 ± 10.54 years), which was statistically significant ( P = 0.028).

Symptomatology

Clinical details were available in 95 (90.5%) of our patients. The main presenting complaint was a swelling (94.73%, n = 90) in the vicinity of the previous operative scar. The other main presenting symptoms were pain (35.78%, n = 34) and irreducibility (10.52%, n = 10). Of the 95 patients, 14.73% ( n = 14) underwent recurrent incisional hernia repairs.

Index operation

An index operation is the previous surgery, which resulted in the incisional hernia. The duration of presentation since the previous surgery was 7.08 ± 7.53 years (minimum = 4 months, maximum = 30 years). Gynecological operations accounted for 68.4% ( n = 65) of our incisional hernias. Patients who had undergone lower segment Cesarian section (LSCS) or tubectomy in the past, presented late-10.19 ± 9.82 years and 11.87 ± 7.9 years, respectively as compared to the hysterectomy group (3.81 ± 4.25 years, P = 0.004). Time of presentation since the index operation was also earlier among our male patients (3 ± 3.93 years). Emergency laparotomies, which are the most common index operations according to literature, constituted only 7.36% ( n = 7) in our series of incisional hernias.

Incisions

The most common incision resulting in an incisional hernia was the lower midline incision (64%, n = 60), followed by the Pfannensteil incision (13%, n = 12).

Surgical details

The most commonly used incision was the vertical elliptical incision excising the previous operative scar. The size of the mesh we have used ranged from 15 ´ 7.5 cm to 30 ´ 20 cm. Dermolipectomy was done in 20 (21.05%) patients.

Postoperative period

Drains were used in all the patients. The period of drainage ranged from 2-11 days, the average period being 5-6 days. Prolonged drainage was encountered in 8.42 % ( n = 8) patients, minor wound infections in 10.5% ( n = 10) patients and major wound infections in 2.1% ( n = 2) patients. But the mesh was not removed in any of the cases. The duration of postop stay was 8.72 ± 3.54 days, (minimum = 4 days, maximum = 26 days). Postop stay was more in patients who underwent dermolipectomy (11.56 ± 4.66 days) than in patients who did not (7.94 ± 2.73 days, P = 0.000).

Follow up

Sixty-five (62%) patients attended our follow-up, which was carried during the first quarter of 2002. Follow-up period was 42.51 ± 22.99 months (~ 3.5 years); minimum = 15 months, maximum =- 95 months (~ 8 years). Twenty-nine (44.6%) patients attended the OPD personally for follow-up. Twenty-six (40%) mailed back the response card after answering the questionnaire. Ten (15.3%) were questioned over the telephone and their response recorded. There was no recurrence in the follow-up group.

Discussion and Conclusion

A literature search was done to compare the results of our technique with other published repairs for the treatment of incisional hernia. Anatomical repairs had a high incidence of recurrence with a reported incidence of 46% following Keel repair ^[2] and 54% following Mayo repair, ^[3],[4] which was unacceptable.

Prosthetic mesh repairs had a lesser incidence of recurrence, especially with the Rives Stoppa repair [Table - 1].

The incidence of incisional hernia was highest among females in the 5 ^th and 6 ^th decades of life. Gynecological operations with a lower midline incision accounted for the majority of the index operations, which resulted in incisional hernia. The preperitoneal plane is the ideal, logical plane for the placement of the prosthetic mesh.

Although this is not a new method of repair, no details are available in literature. The mesh size used in our cases ranged from 15-30 cm, thus indicating most of the cases in this series were large midline hernias. During the dissection, it is important to retain the redundant sheath and sac of the hernias until the end. Trimming of these are done before suturing. Excision in the early phase of the dissection can lead to shortage of tissues for closing and result in tension. Occasionally if the tissue approximation is difficult then another mesh is used to close and maintain the concept of tension-free repair. We had a follow-up of 62% with no recurrence in the follow-up group. We thus believe that preperitoneal mesh repair is the ideal repair technique and is highly recommended for large midline incisional hernias.[10]

Acknowledgment

References

Copyright 2007 - Indian Journal of Surgery

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