Incisional Hernias Approximately 4 million abdominal operations are performed every year and as many as 10 to 20% of these patients

have been estimated to develop hernias at the abdominal incision sites. Any such occurrence is termed incisional hernia and can be regarded as a wound healing failure. The cause of incisional hernia in any given case can be difficult to determine, but obesity, primary wound healing defects, multiple prior procedures, prior incisional hernias, and technical errors during repair may all be contributory. Hernias can occur at sites of defective healing within the approximated incision or at the suture puncture sites created during the closure, or both. Repair of incisional hernias can be technically challenging, and a myriad of methods have been described. The most important distinctions in describing surgical management of incisional hernias are primary vs. mesh repair and open vs. laparoscopic repair. Primary repair methods for incisional hernia include both simple suture closure and components separation, and are open procedures. Simple suture approximation of fascial defect edges predictably results in a suture line under tension. Primary repair, even of small hernias (defects <3 cm), is associated with high reported hernia recurrence rates. In a randomized prospective study of open primary and open mesh incisional hernia repairs in 200 patients, investigators from the Netherlands found that after 3 years, recurrence rates were 43% and 24% for the two methods, respectively. Identified risk factors for recurrence were primary suture repair, postoperative wound infection, prostatism, and surgery for abdominal aortic aneurysm. These investigators concluded that mesh repair was superior to primary repair. In an effort to decrease the suture line tension associated with primary repair, Ramirez first described the components separation technique. Components separation entails the creation of large subcutaneous flaps lateral to the fascial defect followed by incision of the external oblique muscles and, if necessary, incision of the posterior rectus sheath bilaterally. These fascial releases allow for primary apposition of the fascia under far less tension than in simple primary repair. Components separation hernia repair is associated with a high wound infection risk (20%) and a recurrence rate of 18.2% at 1 year. Components separation is most applicable for the repair of incisional hernias when there are converging needs to (a) avoid the use of prosthetic materials, and (b) achieve a definitive repair. Most commonly this occurs in the setting of a contaminated or potentially contaminated surgical field. Mesh repair has become the gold standard in the elective management of most incisional hernias. Mesh repairs can be categorized according to the way in which the mesh is placed as well as its relationship to the abdominal wall fascia. Mesh can be placed as an underlay deep to the fascial defect (intraperitoneal or preperitoneal), as an interlay either bridging the gap between the defect edges or within the abdominal wall musculoaponeurotic layers (intraparietal), or as an onlay (superficial to the fascial defect). Laparoscopic repairs use an intraperitoneal underlay technique. Meshes can be characterized by type of material, each of which has a specified density, porosity, and strength. Broadly, these can be prosthetic or biologic. Permanent prosthetic mesh implants are made of materials that do not degrade over time, whereas absorbable meshes are degraded, primarily by hydrolytic enzyme activity. Biologic meshes are prepared from collagen-rich porcine, bovine, or human tissues from which all antigenic cellular materials are removed. These mesh materials can be chemically treated to cross-link collagen molecules, which increases

strength and durability at the cost of some impairment in host cellular ingrowth. Over time, biologic meshderived collagen can be incorporated into the host tissue, remodeled, and eventually replaced by host collagen. Early in their use, biologic meshes were felt to represent a potentially definitive solution when used to bridge an abdominal wall defect. However, more recent reports show that hernia recurrence rates are excessive in this application. Jin and colleagues found that when human acellular dermis was used to bridge a complicated incisional hernia defect the recurrence rate was 73%, in sharp contrast to a 15% recurrence rate when the same material was used as an onlay or underlay in conjunction with primary closure. Blatnik and associates reported an 80% recurrence rate when human acellular dermis was used to bridge ventral hernia defects, at a cost of $5100 per patient for the mesh alone. Commonly used meshes for incisional hernia repair are listed in Table 35-1. The principal advantages of prosthetic meshes are ease of use, relatively low cost, and durability. Biologic meshes are useful in the setting of contaminated or potentially contaminated fields but are very expensive and, based on the most recent evidence, do not offer the durability of permanent prosthetic meshes unless combined with a primary repair. Absorbable meshes, composed of the same materials as polysaccharide-derived synthetic absorbable suture, provide relatively inexpensive solutions for temporary abdominal wall support in highly contaminated or infected fields. Use of these meshes leaves patients with recurrent ventral hernias that can be definitively repaired when permitted by improved local wound conditions.

ePTFE = expanded polytetrafluoroethylene. Open mesh repair of incisional hernias generally requires incision or excision of the previous laparotomy scar, with care taken to avoid injury to the underlying abdominal contents. The peritoneum and hernial sac are then dissected free from the abdominal wall fascia so that at least 3 to 4 cm of fascia is circumferentially exposed. The mesh can then be sutured into place using an underlay, onlay, interlay, or "sandwich-style" (both underlay and onlay) method. The most successful method is to extensively develop a preperitoneal space to accommodate a large sheet of polypropylene or woven polyester mesh. The mesh, which is isolated from the peritoneal contents, is then secured to the musculoaponeurotic tissues using interrupted nonabsorbable sutures. Tissue ingrowth within the interstices of these mesh types results in dense attachment to whatever tissues the mesh comes into contact with. This effect is desirable when the mesh is located in the preperitoneal position. However, exposure to the underlying bowel ought to be avoided whenever possible. Among the problems attributed to adherence of peritoneal contents to mesh are chronic pain, bowel obstruction, and fistulization to bowel. Polytetrafluoroethylene

(PTFE) does not become incorporated into the surrounding tissues and is not associated with dense adhesions to the intraperitoneal structures. It is therefore commonly used for intraperitoneal applications. Irrespective of technique, the recurrence rate after open incisional hernia repair can be high. In two randomized trials of open mesh repair, one using an underlay technique and one using an onlay technique, the recurrence rates were 20% and 8%, respectively. Laparoscopic incisional hernia repair was first described by LeBlanc and Booth in 1993. Since that time, many would argue, these procedures have become a new gold standard for abdominal wall reconstruction for ventral hernia. In 2000, data from 407 patients undergoing laparoscopic incisional hernia as part of a multicenter trial revealed a recurrence rate of only 3.4%, after a mean follow-up of >2 years. Of the recurrences noted, the overwhelming majority were felt to be secondary to technical errors committed early in the surgeons' experience that were avoided during the later cases. Recently, investigators at Washington University examined pooled data from 45 different series of laparoscopic and open ventral hernia repair. Use of the laparoscopic technique was associated with statistically fewer wound complications, fewer overall complications, and a lower recurrence rate than use of the open technique. These benefits of the minimally invasive technique are achieved by eliminating the requisite large abdominal incision at a location where the abdominal wall blood supply has previously been compromised. In addition, with the laparoscopic technique, the entire undersurface of the abdominal wall can be examined, which often reveals multiple secondary defects that might not otherwise be appreciated. The technique of laparoscopic incisional hernia repair generally involves laterally placed ports for midline defects and contralaterally placed ports for lateral defects. All adhesions to the anterior abdominal wall are divided, with great care taken not to injure the intestine either directly or with thermal or electrical energy. The contents of the hernial sac are completely reduced, but in contrast to open repairs, the sac itself is left in situ. Once the area encompassing all fascial defects is defined, a mesh is fashioned to allow for sufficient overlap (minimum of 3 to 4 cm) under the healthy abdominal wall. After insertion into the abdomen, the mesh is fixed into position with transfascial sutures placed circumferentially around the mesh and spiral tacks placed according to surgeon preference (Fig. 35-11). It has been proposed that transfascial sutures contribute to excessive postoperative pain, and some surgeons have eliminated them from the aforementioned technique, relying solely on spiral tacks for the strength of the repair. LeBlanc reviewed the usefulness of transfascial sutures and cautiously recommended a minimum 5-cm overlap of mesh from defect edge if transfascial sutures are not used.