Incisional hernia

1) Incisional herniae may become apparent during the early months after
surgery when there has almost certainly been some deep wound
dehiscence in the postoperative period.
2)

3)

A poor-quality scar, as a result of a wound infection or faulty closure

technique may disrupt later however, and both morbid obesity and chronic
cough greatly increase the risk.
Easily reducible wide-necked defects may often be ignored.

4)

Some form of elasticated support for comfort is often all that a patient
wishes, but if repair is planned it is important to decide whether only part
of the wound, or the whole wound, needs to be explored.

5)

If there is more than one area of herniation it is usually advisable to repair

the whole wound.

6)

Accurate preoperative skin marking of the extent of the palpable sac and
the fascial defect is helpful.

7)

Access is via the original scar, and excision of the scarred skin gives a
better cosmetic result.

8)
9)

The sac is defined and the plane around it followed to identify the defect.
Before repair, the edges of the defect must be defined by incising the
junction of normal fascia with the attenuated fascial covering of the sac.

10) A shallow peritoneal protrusion from most of a scar need not be opened
and to do so unnecessarily merely increases the risk of small bowel injury,
and of ileus.
11) Therefore, if the peritoneum can be freed from the under-surface of the
abdominal wall it can be left intact, and the fascia repaired over it.
12) A peritoneal sac through a narrow defect should be excised, and the
peritoneum should also be opened if there is any concern that a widenecked sac could be loculated.
13) More often, the peritoneum has to be opened because it cannot be
separated from the abdominal wall, but this has the advantage that the
surgeon has the opportunity to palpate the under-surface of the adjacent
scar for weak areas which need to be repaired at the same operation.
14) If the peritoneum has been opened it may either be closed separately or
with the abdominal wall repair.
15) The edges of the abdominal wall defect are excised so that there is a
freshly cut edge of healthy tissue for closure.
16) The suture technique used is similar to that for any abdominal wall closure
as described above, but particular care must be taken to encompass
healthy fascia in the suture bites.
17) A non-absorbable continuous suture is suitable.

18) If the abdominal wall has retracted laterally and there is any tension, then
a mesh or other technique should be used.
19) There is also increasing evidence that some form of mesh repair may be
the better option, even when the surgeon is confident that satisfactory
tension-free apposition of the fascia can be achieved by using a simple
suture technique.
20) An on-lay mesh, placed over the closed fascia and secured to it with
sutures, is the simplest technique.
21) However, any superficial wound infection is likely to result in a chronic
infection in the mesh.
22) Vacuum drainage of the subcutaneous fat to prevent postoperative
haematoma collection and prophylactic antibiotics will reduce the
incidence of this complication.
23) Frequently the fascial edges of an incisional hernia do not oppose without
tension.
24) Several techniques which mobilize the abdominal wall fascia to close large
defects have been described. For example, longitudinal incisions may be
made through the lateral side of the anterior rectus sheath which is then
elevated off the muscle, folded medially and sutured in the midline. A
mesh overlay can be used in addition to ensure extra strength to this
repair. This is an operation which, although attractive in theory, is
disappointingly difficult to execute satisfactorily, especially when there is
extensive abdominal scarring. Most surgeons, however, when faced with
this problem would use mesh to bridge the defect in the abdominal fascia,
as described below.
MESH IN ABDOMINAL WALL REPAIR
1) The development of inert meshes, such as monofilament polypropylene,
has greatly simplified the treatment of most difficult herniae.
2)

A mesh may be used over or under a simple repair to provide additional

strength.

3)

The mesh must be placed so that it is in contact with normal tissue for
some distance on either side of the closure, and a few sutures are then
used to prevent it becoming displaced in the immediate postoperative
period. Ultimately, the mesh becomes incorporated into the tissues and
adds greatly to the strength of the final scar.

4)

Alternatively, a mesh may be used to bridge a defect in the abdominal

wall which cannot be closed without unacceptable tension.

5)

The defect may be a large hernia, a congenital abnormality, or represent a

portion of the abdominal wall lost through trauma, or excised for
malignancy.

6)

The ideal position for such a mesh is between the closed peritoneum and
the abdominal wall, where intra-abdominal pressure pushes it against the
muscles and fascia, and the peritoneum separates it from the bowel. This
is only possible if the peritoneum can be separated from the overlying
muscles and sufficient peritoneum from the sac can be saved to allow

peritoneal closure. Unfortunately, this situation is often unattainable and

the mesh has to replace both the peritoneum and the fascia of the defect.
In this position a mesh may be in direct contact with bowel, if omentum
cannot be placed between. Although there are concerns that this might
increase the risk of fistula formation and mesh infections, the results of
recent studies have suggested that these fears may be unfounded.
7)

A mesh should be several centimetres larger than the defect it will

replace, as it is only in the areas of overlap that it can be incorporated into
tissue and provide any inherent strength.

8)

An extraperitoneal or an intraperitoneal mesh first requires four sutures

to prevent any rolling of the edges of the mesh.

9)

The edges of the fascial defect are then sewn with a continuous nonabsorbable suture down onto the top surface of the mesh, with care being
taken to prevent injury to any underlying viscus.

10) Any implanted mesh may become infected. The infection is difficult to
eradicate as bacteria may be in a protected environment where there is
poor antibiotic penetration, and in spaces too small to allow access to
neutrophils.
11) Recent advances in mesh material and pore size have improved this
problem, but the surgeon should still be very wary of using a mesh in any
potentially infective situation, and antibiotic cover is always
recommended.
12) A vacuum drain in the subcutaneous fat reduces the risk of a haematoma
as a potential culture medium for infection.
13) An infected non-absorbable mesh almost always has to be removed
completely.
14) Smooth inert patches of expanded polytetrafluoroethylene (ePTFE),
marketed as Gore-Tex, are an alternative to polypropylene meshes.
15) The reduction in fibrosis may decrease bowel complications when the
mesh has to be in direct contact with the bowel, but the poor tissue ingrowth inevitably results in a weak attachment of the patch to the
abdominal wall and a greater risk of recurrence.
16) Compound meshes with an inner layer of ePTFE and an outer layer of
polypropylene may have a role.
17) Inert collagen meshes are a recent advance, which can be used in the
presence of infection. They can be of great value in bridging a fascial
defect left when an infected mesh has had to be removed. However, as
this material is extremely expensive, its use is limited to situations where
other techniques are inappropriate.