INCISIONAL HERNIAS

Background
• 2 Million laparotomies/year in US
• Incisional hernia rate between 2 - 15%
• Approximately 100,000 repairs performed/year

Presentation
• First sign- Asymptomatic bulge around incision
• 50% will present within 1 year from initial surgery
• with time, become painful with straining, movement
• vomiting/obstipation usually involved with incarceration/strangulation

Risk Factors
• Wound infection- # 1 abdominal distension pulmonary complications, male gender,
obesity, age >65, emergency procedures, malnutrition, type of closure (continuous vs
interrupted), suture material used for closure (absorbable vs. non-absorbable), mass
closure vs layered closure
• Hodgen et at. 2000 - midline laparotomy wounds closed with non-absorbable,
continuous running stitch results in significantly less post-up incisional hernias (32%
less)
• Non-absorbable sutures nidus for infection/sinus tract formation, also may cut into
fascia late ventral hernia, so trend is towards slowly absorbable monofilament
• Continuous running sutures faster closure and spreads tension evenly on wound over
entire length

Tenants of repair
• Anatomic reconstruction of abdominal wall
• No tension

Repairs
1 . Primary Repair
• Using sutures to approximate the edges of the fascial defect
• < 3-5cm detects
• 4: 1 ratio of suture length to wound length
• Up to 25-55% recurrence rates reported - no matter how small defect, tension always
present on repair.
• In effort to reduce tension, relaxing incisions or internal retention sutures

2. Mesh Repairs
• Types of mesh -absorbable. permanent with incorporation into tissue, permanent
without incorporation, composite
• Polypropylene Marlex/prolene- permanent, nonabsorbable, highly inflammatory
reaction, allows ingrowth of collagen/fibroblasts
• Polyester Mersilene-permanent, nonabsorbable, significantly greater fistula, infection

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 and hernia recurrence
• PTFE (Gore-Tex) - permanent microporous/nonabsorbable, fewest bowel
complications
• Vicryl knitted polyglactin/Dexon knitted polyglycolic acid - absorbable-used only in
cases where infection is significant risk and primary closure not option
• Composite polypropylene/PTFE
• Complications from mesh placement- infection fistula, nidus for adhesions
intestinal obstruction

• Onlay mesh
o used to reinforce the primary repair- usually sutured to anterior rectus sheath
o 5 cm margins from aponeurotic defect
o Advantage- keeps mesh separated from abdominal contents
o Disadvantage- large subcutaneous dissection seromas infection

• Inlay mesh repair

o Hernia sac excised and healthy fascial/muscular edge identified around defect
o Mesh is circumferentially sewn to fascial edge
o Recurrence rate 10 - 20%
o significant tension at the attachment points of fascia and mesh

• Retrorectus sublay repair (Rieves-Stoppa)

o dissection between rectus muscle and posterior rectus fascia/ preperitoneal space
o posterior rectus fascia approximated
o Mesh is placed in the space provided - extend at least 5 cm beyond aponeurotic
defect
o Anterior rectus sheath approximated
o Recurrence rates < 10%
o Pain is common - lateral fixation points, disappears after ingrowth

• Intraperitoneal underlay mesh repair

o Possible because of bilayer prosthesis
o Places mesh intraperitoneal with nonadhesive side down
o Fixation to fascial edge, posterior abdominal wall laterally partial thickness, full
thickness muscular facial abdominal wall fixation at least 5 cm lateral to hernia
defect
o Allowed for gastroscopic repair - mesh inserted thru trocar site, fixed to
abdominal wall with partial thickness tacks or full thickness abdominal
muscular/fascial wall sutures
o Rate of recurrence 5%

• Laparoscopic technique
o First described l 993
o Ensure adequate coverage by 3 cm overlap
o Tacks are deployed along borders of prosthesis
o Mean operative times 90 minutes

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 o Average hospital stay 2 days
o Most serious complication - bowel injury
o Recurrence rates 5%

Sources
• Cameron's Current Surgical Therapy
• Hodgson et al. The search for an ideal method of abdominal fascial closure. Annals of
Surgery, 2000
• Millikan, Keith. Incisional hernia repair. Surg Clin N Am, 2003

Henry Lin, M.D.

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