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

Contents:

 

 

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NEW TECHNIQUES IN THE REPAIR OF INCISONAL HERNIAS

 

Incisional hernias (IH) account for approximately 80% of the ventral hernias seen by surgeons. Van’t Riet and colleagues recently reported that closing incisions with slowly absorbable sutures had the same results as non-absorbable sutures, but with less chronic pain than the permanent sutures.10 Sorensen and coworkers recently confirmed what Read first described many years ago; ie, smoking is an independent risk factor (four-fold increase) for development of IH.11 In 2003, Raffetto and colleagues reported a nine-fold increase in IH in patients who have a midline incision for repair of their abdominal aortic aneurysm.12
The first major innovation in VIH repair techniques is the laparoscopic approach to these hernias. Whereas it is seen as a recent innovation, it has been 13 years since the first report of a laparoscopic VIH repair. It has been confirmed by several studies that the main advantages of the laparoscopic repair for large hernias are fewer wound problems and quicker recovery than the open approach, especially when compared to the “gold standard,” Rives-Stoppa repair. As Heniford et al. reported, the recurrence rate is as low or lower than the Rives-Stoppa with fewer complications, and other studies have reported similar results.13 One disadvantage of the laparoscopic repair is that the rectus muscles are not reapproximated to the midline as can often be done with open repair of VIH. The proper functioning of the abdominal wall is aided significantly by having the rectus muscles in the midline. More importantly, in the laparoscopic repair bowel injury can be more readily NOT seen when compared to the open repair, and a bowel injury not seen more often than not leads either to death or tremendous morbidity. If this innovation is to endure as a technique for repair of VIH, surgeons must realize these facts, and if adhesiolysis is too difficult or any question exists regarding injury to bowel, the patient needs to be opened to avoid catastrophic complications.
In the last two to three years, another IH repair technique that has received a lot of attention is “components separation.” This technique was described in 1990, but as it was in the plastic surgery literature it mostly went unnoticed by general surgeons until recently.14 Many modifications of the original technique were described by, but the essential idea is developing skin and subcutaneous flaps far laterally, incising the posterior rectus sheath, and mobilizing the muscle off of the sheath on both sides. The aponeurosis of the external oblique is then incised (again on both sides) over the entire length. This movement of the muscles allows the rectus muscles to be closed in the midline.
Fabian and colleagues reported good success in the post-trauma victim who has had the “planned ventral hernia” as damage control, skin grafted, and then later returned for closure.15 However, this is different from the true incisional hernia. Bleichrodt and colleagues evaluated this method for VIH repair in true incisional hernias and reported in a short follow up of 16 months, a 32% recurrence rate, and a similar rate of significant wound problems.16 Their conclusion was that the component’s separation method is best saved for contaminated situations in which the use of synthetic mesh is contraindicated.
Mentioned earlier was that surgeons in the USA were late to adopt the Rives-Stoppa method for repair of VIH. Whereas not a new procedure, this technique certainly was an innovation in the 1970s and an argument could be made it has been a recent innovation to surgeons in America. Without question, it is the open procedure of choice because of the lowest rate of recurrence when compared to other open methods of VIH repair. As mentioned earlier, this method was developed to get the mesh behind the defect, but off of the viscera because the only meshes available were uncoated PPM and polyester.
Now that multiple meshes can be safely placed intraperitoneally, the authors have turned to what we call an intraperitoneal Rives-Stoppa type of repair of VIH. The first step is begun by developing skin and subcutaneous flaps as far lateral as possible on both sides of the abdomen. This is done for two reasons. First, it is necessary to get back away from the poor-quality fascia next to the hernia edge and into good, healthy fascia in which to place sutures; second, it allows bringing the hernia edges back to the midline to cover mesh and decrease the chance of mesh infection if wound problems develop. In addition, the mesh can be sutured behind the fascia, 6 cm-8 cm from the edge of the defect in a running continuous fashion behind the fascia. (Some surgeons do an intraperitoneal repair without developing these flaps, which requires bringing interrupted sutures up through the entire thickness of the abdominal wall, including the skin.) The mesh is placed into the peritoneal cavity and a #1 Prolene on a large needle is used to suture the mesh at the 6 o’clock position 6 cm-8 cm back into good healthy fascia and another is placed at the 12 o’clock location. These stitches are then run in a continuous fashion as a series of “U” stitches going down through the fascia, down through the mesh, up through the mesh, up through the fascia etc., in a running fashion. After this has been done 360°, 6 cm-8 cm back into good healthy fascia, the sutures are tied and a large piece of mesh is behind the hernia defect with good overlap in all directions. The rectus muscles (or what is left of them) are sutured in the midline to aid in function of the abdominal wall, as well as to protect the mesh in case of wound problems. Gillion and colleagues compared placement of ePTFE in the Rives-Stoppa method with intraperitoneal placement and reported equivalent results.17 We have found the same with what we believe is a better cosmetic result and an easier repair to do.
Lastly, something should be said about one of the most difficult to repair VIH, the parastomal hernia. Repair of this hernia has had a recurrence rate in the 60%-80% range in multiple studies. Rubin and colleagues reported that suture repair alone yielded a 76% recurrence rate; moving the stoma had a 33% recurrence and caused a new hernia in 52%.18 Mesh repair improved the recurrence rate to a still unacceptable 30%, mainly because of the way the mesh was placed. Obviously, preventing the hernia in the first place would be best, and a recent randomized, prospective trial using lightweight PPM at the time of stoma creation was done to determine whether the hernia could be prevented. At the time of stoma creation, a 10x10 cm2 piece of mesh, with a cross cut in the middle to pass the bowel through, was placed in a retrorectus position. Fifty-four patients were randomized and follow up averaged 38 months. Fifty percent of those with no mesh formed parastomal hernias, and only one hernia occurred in the mesh group. No infections of the mesh were noted.
After the hernia had occurred, Rubin and co-workers showed that mesh is required for repair, but the way in which to place the mesh is critical.18 The most common method in the USA is to cut a keyhole-type slit in the mesh and wrap the tails around the bowel. The problem with this repair is that the keyhole creates a weak area in the mesh through which the bowel can herniate.
A better approach for mesh use was described in 1971 by Sugarbaker, but received little attention until recently as we began teaching the method when teaching laparoscopic hernia courses .19 Sugarbaker originally described his technique by way of laparotomy, but it also can be done laparoscopically. The method involves placing the mesh intraperitoneally over the defect without cutting a slit. The bowel simply is tunneled out one side of the mesh between the mesh and peritoneum. Thus, there is no weak area in the mesh and Sugarbaker had no recurrences at four to seven years of follow up.
Davol has recently introduced a PPM/ePTFE combined mesh made specifically for parastomal hernia repair. The PPM is a heavy-weight mesh, however, with all the problems discussed earlier, and the mesh has a keyhole slit. The keyhole is placed away from the hernia and the solid, reinforced area of ePTFE is placed over the defect. The authors have tried this mesh in three repairs with one recurrence between the bowel and keyhole. Long-term follow up and more use of this new mesh will be required to delineate its use for this type of hernia.