Open onlay incisional hernia repair

the simple solution?

Andrew Kingsnorth
Peninsula Medical School
Plymouth, UK

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The aims of surgery

Open repair reconstitutes the abdominal wall

anatomy
Open repair returns physiological function to the
abdominal wall
Onlay or sublay techniques are the choices
Hybrid operations (partial abdominal wall closure,
with exposure of mesh to viscera = intraperitoneal
mesh) are not recommended

Incisional hernia: a heterogeneous problem

Mesh technique: Position

Onlay = superficial to aponeurosis, subcutaneous

(Chevrel)
Sublay = prefascial/preperitoneal, retromuscular (Rives)
Inlay = between fascial edges rarely required

Open surgical procedures for incisional hernias.

Den Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW
Cochrane Database of Systematic Reviews 2008, Issue 3,
Art No: CD006438

RCTs comparing different techniques of open repair

8 identified (1 excluded), 1141 patients enrolled
2 trials = onlay vs sublay. No difference, except operative
time shorter for onlay
Comparison between LW and standard mesh showed a
trend for more recurrence in LW group
There was insufficient evidence to advocate the use of
components separation technique

Incisional Hernia Repair in Sweden 2002

(LA Israelsson et al,
Hernia 2006; 10 : 25861)

n = 869 reported from 40 hospitals

Midline in 65%; consultants performed the repair in 84%
40% suture repair
60% mesh repair (54% onlay; 44% sublay, 1% lap or
inlay)
This study has led to instigation of a national incisional
hernia register

Choice of mesh

Mesh requirements for

open and laparoscopic
repair are different

No requirement for
anti-adhesive mesh
surface in open repair

Randomized clinical trial comparing lightweight composite mesh

with polyester or polyproylene mesh for incisional hernia repair
Conze J, Kingsnorth AN, Flament JB et al
Br J Surg 2005; 92: 1488-93

Randomized clinical trial comparing lightweight composite

mesh (LW) with polyester or polypropylene mesh (HW) for
incisional hernia repair
n = 165; 17% (LW) vs 7% (HW), p=0.052
No difference in QoL, return to activity
No difference in abdominal wall compliance (n = 80,
unpublished data)

Abdominal wall compliance: polypropylene versus Vypro

Surveillance of shrinkage of polypropylene mesh

used in repair of ventral hernias
(Vega-Ruiz, Cir Esp 2006)

n = 23 midline ventral hernias, diameters of at least 5cm

pp mesh (9 onlay, 14 sublay) marked with clips at longest
transverse and longitudinal axes
Xrays performed at 1, 3, 6 and 12 months
Distance between clips measured and area of mesh calculated
Reduction in area = 12% (1 month), 24% (3 months), 29% (6
months), 34% (12 months)

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What measures can be adopted to counteract mesh

shrinkage (and structural alterations)

Overlap of 4-5 cm = mesh

of 8-10cm width after
complete fascial closure

Secure peripheral fixation

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Onlay mesh: peripheral fixation, adequate

overlap

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Incisional hernia: loss of domain or second

abdominal cavity

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Relaxing incisions

Single or multiple incisions in anterior rectus

sheath used in former times (Chevrel)
Longitudinal incision in external oblique
aponeurosis for rectus advancement (up to 20cm)
used in the last decade (components separartion
= Ramirez technique)

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Components separation (Ramirez technique)

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Components separation (Ramirez technique)

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Components separation (Ramirez technique)

with onlay polypropylene mesh sutured to the
cut lateral edges of the external oblique

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Open onlay mesh repair for major abdominal wall hernias with
selective use of components separation and fibrin sealant
Kingsnorth AN, Shahid MK, Valliattu AJ, Hadden RA, Porter CS
World J Surg 2008; 32: 26-30

Prospective 24 month
audit: June 2004 06
116 patients with major
(>10cm) incisional hernias
Follow-up via outpatient
clinic review.
Quality of life assessed by
a validated questionnaire
and telephone follow-up.

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Open onlay mesh repair for major abdominal wall hernias with
selective use of components separation and fibrin sealant
Kingsnorth AN, Shahid MK, Valliattu AJ, Hadden RA, Porter CS
World J Surg 2008; 32: 26-30

Fascial closure required CS

in 18%
Fibrin sealant was applied
in 19% (extensive skin
flaps)
Seromas in 9.5%
Deep wound infections in
1.7%
Recurrences in 3.4% at
15.4 months

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Reduction in seroma formation

Closed suction drainage in the lateral and

redundant space where the mesh has been
placed
Fibrin sealant

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Fibrin sealant

Not evaluated in any (incisional) hernia trials

Used for fixation and fibroblastic infiltration in
inguinal hernia (ongoing trials)
Merit in incisional hernia will be in seroma reduction
rather than fixation (require non-absorbable
sutures)
Pilot studies and randomised trials are required

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Merits of the onlay technique

Technically easy to perform

and to teach
No risk of visceral contact
between mesh and peritoneal
contents (compare sublay
below the arcuate line of
Douglas)
Easy combination with
relaxing incisions
(components separation)
Versatile (not just the midline,
all areas of the abdominal
wall can be covered)

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