Publication:
Surgical Technology International XVI - Hernia Repair
Article title:
Innovations in Ventral Hernia Repair

Contents:

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Author(s)

Guy R. Voeller, M.D., F.A.C.S.

Professor of Surgery University of Tennessee, Memphis Memphis, Tennessee, USA

 

Abstract
There is a renewed interest in the surgical repair of ventral hernias due to new meshes and new techniques to use these meshes. The standard of care for ventral hernia repair, the Rives-Stoppa repair, is now more commonly done in the USA. Originally, only polypropylene mesh (PPM) or polyester meshes were available for this technique and they had to be placed extraperitoneally. With development of the laparoscopic approach for ventral hernia repair using expanded polytetrafluoroethylene (ePTFE), newer coated meshes for intraperitoneal placement were developed. Companies have also combined polypropylene mesh (PPM) and polytetrafluoroethylene (PTFE) into a unique mesh and numerous biologic meshes are being introduced. All of these meshes have led to several new methods for ventral hernia repair (including parastomal hernia) and in those cases where mesh is not indicated, one non-mesh repair, the components separation, has received renewed attention.

INTRODUCTION

 

Surgical repair of ventral/incisional hernias (VIH) has recently become a “hot” topic because of the many new prosthetics available and new techniques developed to use these new materials. Until Usher introduced the first truly usable prosthetic polypropylene mesh (PPM) in 1958 for hernia repair, autogenous tissue was used (ie, the Mayo vest-over-pants repair) in the vast majority of VIH repairs.1 The prevailing thought throughout the time period of 1960-1980s was that the risk of mesh was too high to warrant its use unless no other solution to the hernia problem was available to the surgeon. However, several studies in the 1980s and early 1990s showed that the recurrence rate for repair of VIH was as high as 40% if suture repair alone was used and the “routine” use of mesh began to be reported.2 Polyester mesh was developed before polypropylene, and had been used for inguinal hernia repair successfully in the late 1960s. In the mid-to-late 1980s, Rives and Stoppa in France reported the use of polyester mesh for VIH repair in two large series.3,4 The recurrence rates were low compared to suture repair (5%-10%), and routine use of mesh for VIH repair became more prominent. As mesh use became more frequent, it was apparent that proper placement of the mesh was necessary to keep the recurrence rates low with few complications. Rives and Stoppa used a retrorectus placement of the mesh for several reasons. They realized that placing the prosthetic behind the defect with large overlap of the defect in all directions took advantage of Pascal’s Principle of hydrostatics. The forces that caused the hernia are currently used to hold the mesh in place and decrease the chance of recurrence. However, polyester could not be placed in direct contact with the viscera or ingrowth would occur to the bowel and fistulas, infections, and other problems would occur. This is why the retrorectus plane was chosen; the mesh is behind the hernia and off of the bowel. The Europeans were more advanced than the surgeons in the USA, because of the French influence. Surgeons in the USA used mesh mainly as an interposition or an onlay and recurrence rates with mesh, whereas less costly than suture repair, were still not as good as the Rives-Stoppa type repair. The well-known herniologist, George Wantz, went to France to learn the repair of Rives and Stoppa, brought it to North America, and introduced it to us in Memphis. Despite the best efforts of Dr. Wantz, the repair was not well known in the USA except by a few herniologists. In the early 1990s, several surgeons began to evaluate the laparoscopic approach for repair of VIH. It was natural that we try to base our laparoscopic approach on the same principles, as our open approach of choice was the Rives-Stoppa repair. It was interesting that pioneers in laparoscopic VIH repair, such as Toy, Park, and Gagner, used the same principles In developing their techniques for laparoscopic repair. This innovation in technique for repair of VIH during the last ten years has led to an explosion of innovations, both with respect to meshes for VIH repair and techniques used to place these meshes that would not otherwise have occurred.