Hernia (2006) 10: 258261 DOI 10.

1007/s10029-006-0084-4

O R I GI N A L A R T IC L E

L. A. Israelsson S. Smedberg A. Montgomery P. Nordin L. Spangen

Incisional hernia repair in Sweden 2002

Received: 9 October 2005 / Accepted: 12 February 2006 / Published online: 23 March 2006 Springer-Verlag 2006

Abstract Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the dierent repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349
L. A. Israelsson Department of Surgery and Perioperative Science, University, Umea , Sweden Umea S. Smedberg Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden E-mail: sam.smedberg@helsingsborgslasarett.se A. Montgomery Department of Surgery, University Hospital of Malmo , Malmo , Sweden E-mail: agneta.Montgomery@skane.se P. Nordin stersund Hospital, O stersund, Department of Surgery, O Sweden E-mail: par.nordin@jll.se L. Spangen Department of Surgery, Karlstad Hospital, Karlstad, Sweden E-mail: leif.spangen@mail.ip-only.net L. A. Israelsson (&) Kirurgkliniken, Sundsvalls sjukhus, SE851 86 Sundsvall, Sweden E-mail: Leif.Israelsson@lvn.se Tel.: +46-60-181000 Fax: +46-60-181439

(40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register. Keywords Incisional hernia Incisional hernia repair Suture repair Mesh repair Wound complications Incisional hernia recurrence

Introduction
Incisional hernia is a common complication after abdominal surgery with a reported incidence of 11 20% [16]. Several techniques for incisional hernia repair are used including suture repair, open mesh repair, and laparoscopic mesh repair [69]. A recurrence rate of more than 50% may be encountered after suture repair [10]. The regenerative ability of aponeurotic tissue is very limited and therefore, the use of a synthetic prosthetic mesh has been advocated for incisional hernia repair. This has led to a lower recurrence rate [810]. Mesh repair for incisional hernia can be performed with an onlay technique, a sublay technique or a laparoscopic technique. Good results have been reported with all these methods from specialized surgical units [7, 8, 1114]. To what extent these methods are used in nonspecialized units and the subsequent rates of wound complication and recurrence are not known. The aim of this study was to investigate the methods of incisional hernia repair that were employed in Sweden during the year 2002 and the subsequent rates of wound infection and incisional hernia recurrence.

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Methods
In January 2004 all surgical departments in Sweden were asked to participate in a survey by answering a questionnaire, including a section for each patient, concerning incisional hernia repairs performed at their department during 2002. The patient section included basic demographics, such as sex, age, height, and length (and thereby body mass index). Data on emergency repair, use of prophylactic antibiotic therapy, the incision used at the previous operation and indication for operation were asked for. If the incisional hernia was a recurrence, the technique used at the previous repair was asked for. Perioperative data including whether or not the surgeon performing the hernia repair was a specialist, the size of the abdominal wall defect in centimetres, method of incisional hernia repair, choice of the suture material, and operation time were registered. Postoperative complications and data on follow-up for detection of incisional hernia recurrence in 12 months or more after repair were asked for. The responding departments were categorized, as university hospital, county hospital or community hospital. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software. Mean values are presented with 95% condence intervals (CI).

Table 1 Previous incision in 869 incisional hernia repairs Incision Midline Transverse Subcostal Laparoscopic port Muscle splitting right fossa Pfannenstiel Unknown n (%) 569 (65.5) 83 (9.6) 74 (8.5) 55 (6.3) 53 (6.1) 31 (3.6) 4 (0.5)

Table 2 Method of repair in 869 incisional hernias Method of repair Suture repair Mesh repair Inlay Onlay Sublay Laparoscopic Unknown n (%) 349 (40.2) 516 (59.4) 4 281 228 4 3

Table 3 The rate of wound infection related to the method of repair and the use of prophylactic antibiotic therapy in 821 incisional hernias Method of repair Wound infection (%) Prophylactic antibiotic No Yes 20 of 135 (14.8) 33 of 357 (9.2)

Results
From the questionnaire a total of 869 incisional hernia repairs were reported from 40 hospitals (range 263 hernias per department). Six of the nine university hospitals in Sweden reported 195, 19 of the 20 county hospitals 526 and 15 of about 40 community hospitals 148 repairs. Mean age was 61 (95% CI 5962) years (range 22 94) and mean body mass index was 29 (95% CI 2830), and 540 (62.1%) patients were female. The previous operation had been a gynecologic procedure in 146 (16.8%) cases. In 89 (10.2%) cases the incisional hernia repair was an emergency procedure. Of these, 59 (66.3%) had a suture repair and 30 a mesh repair. The previous operation had most often been through a midline incision (Table 1). The incisional hernia was a recurrence in 148 (17.0%) cases and in 45 (30.3%) of these, the previous repair had been with a mesh. A specialist surgeon performed the repair in 782 (83.8%) cases. A suture repair was performed in 349 (40.2%) incisional hernias (Table 2). An absorbable suture was used in 124 of the 342 (36.3%) suture repairs and in 77 of 447 (17.2%) when a mesh was used. Mean length of operation with suture repair was 65 (95% CI 6170) min in 294 patients, with onlay mesh repair

Suture repair Mesh

13 of 209 (6.2) 6 of 120 (5.0)

92 (95% CI 8897) min in 242, and with sublay mesh repair 102 (95% CI 96108) min in 198 patients. Wound infection occurred in 33 of the 345 (9.6%) patients with suture repair, and in 39 of the 480 (8.1%) with mesh repair. Prophylactic antibiotic therapy was administered in 501 (57.7%) patients: 136 of the 348 (39.1%) patients when suture repair was performed and 367 of 490 (74.9%) when a mesh was used. A high rate of wound infection was encountered when prophylactic antibiotic therapy was employed especially with suture repair (Table 3).
Table 4 Incisional hernia recurrence 1224 months after surgery related to the method of repair in 471 incisional hernias Method of repair Suture repair Mesh repair Inlay Onlay Sublay Laparoscopic Recurrence (%) 51 of 175 (29.1) 0 of 2 33 of 171 (19.3) 9 of 123 (7.3) 0 of 3

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The rate of incisional hernia recurrence correlated with the method of repair. The highest recurrence rate was reported with suture repair (29.1%) and the lowest with a sublay mesh repair (7.3%) (Table 4). A higher incidence of recurrence was reported when the abdominal wall defect was greater than 3 cm together with the suture repair or onlay mesh repair. With sublay mesh repair the recurrence rate did not correlate with the size of the defect (Table 5).

Discussion
Incisional hernia repair practice in Sweden was virtually unknown prior to this national survey. Our aim was to obtain data from as many surgical units as possible. Answers were received from six of the nine university hospitals in Sweden, 19 of the 20 county hospitals, and from 15 of about 40 community hospitals. This was a retrospective study and, the information requested being obtained from patients notes entails some limitations. Since data from the notes at least 1 year after the incisional hernia repair were asked for, results from the follow-up examination were not available in 46% of the patients. Sweden has a national health care system with very few private hospitals, which is why patients usually attend their local hospital. Lack of data may therefore be cautiously interpreted as the absence of signicant postoperative problems. Complications of importance have probably been reported in this survey. Recurrence is most likely to be under-reported, as only cases signicant enough to cause the patient to return to the hospital for counselling, or are diagnosed at occasional clinical follow-up were disclosed. The true rate of recurrence may be expected to be twice as high as that obtained in this fashion, judging by the experience gained from the Swedish hernia register [15]. Furthermore, the length of follow-up in this survey was limited between 1 and 2 years. Statistical analysis of an uncontrolled data, such as the results of dierent methods of repair is questionable. Suture repair can be performed in dierent ways, and the dierent mesh techniques can be sub-optimal because of insucient preparation of tissues and insucient overlapping of the mesh. Information on how the
Table 5 Incisional hernia recurrence 1224 months after surgery related to the size of the abdominal wall defect and method of repair in 290 incisional hernias Method of repair Recurrence (%) Size of abdominal wall defect 3 cm Suture repair Onlay mesh repair Sublay mesh repair 16 of 60 (27) 3 of 29 (10) 1 of 22 (5) >3 cm 13 of 37 (35) 17 of 75 (23) 4 of 67 (6)

dierent methods of hernia repair were performed was not sucient enough to allow thorough analysis of the dierent techniques employed. The outcome of the surgeons intention to treat, however, can be evaluated. The Swedish surgeons response to the survey was encouraging. The high percentage of surgical specialists performing incisional hernia repair indicates that this is considered to be a major procedure. The general impression among surgeons that a high incidence of incisional hernia occurs after gynecological surgery was not conrmed in this survey, these procedures representing less than 20% of the material. Another myth that incisional hernia is infrequent after transverse, subcostal or muscle-splitting incisions, and after laparoscopic procedures is contradicted by the fact that one third of the incisional hernias in this survey followed such procedures (Table 1). About 60% of incisional hernias were treated by mesh repair. Fortunately, less than 1% of mesh repairs were inlay procedures in accordance with the recommendation not to use this technique [16]. Surprisingly laparoscopic repair was also unusual at this time. This technique, however, has gained in popularity over the last 2 years, and clinical studies of the technique have recently been initiated in Sweden. Of the mesh repairs, 55% were onlay procedures. It is unlikely that they were all performed with wide subcutaneous dissection allowing for a generous overlap, and multiple xation points. In our experience, an onlay mesh procedure is sometimes used as an adjunct to suture repairs, and not used as the preoperatively planned method of choice. This is indicated by the fact that mean length of operation with onlay mesh repair exceeded that of the suture repair by less than 30 min. Meshes were less frequently used in emergency cases. There is a current debate on this issue in the literature, and more liberal use of meshes in the emergency situation is now reported [17]. Wound infection is a major problem reported to occur in 418% of cases after open mesh repair [8]. Considerably lower infection rates are reported after laparoscopic techniques, 04% [14, 18]. Infection and antibiotic prophylaxis is of great concern, particularly with the use of mesh. Antibiotic prophylaxis is recommended with mesh repair [7] since a mesh infection may result in fulminant sepsis demanding mesh extraction, or stula formation. Even hernia repair without mesh is associated with a high rate of wound infection [8]. Twenty-ve per cent of mesh repairs in the survey were not covered by antibiotic prophylaxis. Unexpectedly the wound infection rate was higher in patients receiving antibiotic prophylaxis, which may in part be explained by selection of patients with an increased risk for infection. Further studies on incisional hernia repair and antibiotic prophylaxis are needed. Recurrence occurred in 29% after suture repair and in 14% after mesh repair. The sublay technique had the lowest recurrence rate 7%. Previous clinical studies have shown that an incisional hernia size greater than

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4 cm results in a higher recurrence rate [19]. Similar results were obtained in this survey with higher recurrence rates after suture repair and onlay mesh repair in hernias more than 3 cm in diameter. The absence of certain data requested, indicates a need for improvement in the patient documentation regarding data, such as the size of the defect, the suture material, and the size and type of mesh used. Furthermore, this information is essential in helping the future surgeon to select methods when operating in the same area. Lack of data also makes evaluation of operative results more dicult. The survey revealed a great interest in incisional hernia surgery amongst the units participating who wished to know how their results compared with the total results. Feedback of this nature could only lead to an improvement in the use of standardized techniques. This survey illustrates that there is denitely room for improvement in incisional hernia surgery in Sweden. The use of standardized techniques and a prospective protocol are needed. This study has initiated the instigation of a national incisional hernia register.

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