Incisional Hernias

Laura Withers, M.D. St. Lukes Roosevelt Grand Rounds July 6, 2005

Anatomy of the Abdominal Wall

Superior to the arcuate line Inferior to the arcuate line

Definition
A hernia is the protrusion of an organ through the wall that normally contains it. An incisional hernia occurs in the area of an old surgical scar. A ventral hernia occurs in the abdominal wall.

A Problem Encountered and Produced by Surgeons:

In the U.S. approximately 2 million laparotomies are performed each year. The incidence of incisional hernias is reportedly between 3%-20% . This results in an estimated 60,000-400,000 ventral hernia repairs per year. No repair, approach or material has become a gold standard in the treatment of this problem.

Clinical Presentation
More than half of incisional hernias occur within the first two years after primary operation. A diffuse bulge directly under or adjacent to a previous incision. Increased protrusion with valsalva or standing. Cosmetic concerns or interference with work or activity are common complaints. Pain is unusual as a presenting symptom unless there are incarcerated or strangulated structures. The natural history of an incisional hernia is to enlarge and become symptomatic.

Clinical Presentation and Workup

Physical exam may not be adequate in obese patients, patients with significant rectus diastasis, patients with laxity due to spinal injury or patients who have had multiple prior abdominal surgeries. In this case UGI, ultrasound or CT may be used.

Risk Factors
Age Above 65 or 70 Male Gender Malnutrition Sepsis Anemia Uremia Ascites / Liver Failure Diabetes Pulmonary Disease Smoking Abdominal Distension Obesity Coughing / Retching Urinary Retention Post-op Ileus Peritoneal Dialysis Wound Infection Corticosteroids Chemotherapy Immunosupression

Etiology
Mechanical Factors Intra-abdominal pressure overwhelming a weakness in the abdominal wall. Pathologic changes in collagen that adversely affect wound healing. Type I collagen is dominant in a mature scar Type III collagen dominates in the early stages of wound healing Factors such as smoking, malnutrition, immunocompromise, wound infection and underlying diseases are now understood to interfere with normal collagen metabolism.

Prevention of Incisional Hernias

The strength of a wound lies in the musculoaponeurotic layer.
Oblique or transverse incisions are preferred in many cases because the pull of the lateral abdominal wall muscles is parallel to the incision and there is less distracting tension than that on vertical incisions. because the tension on the suture lies perpendicular to the orientation of fibers in the abdominal wall fascia. Thus the suture is less likely to pull through.

1.

Kocher or Right Subcostal Incision: oblique abdominal incision paralleling the thoracic cage on the right of the abdomen for cholecystectomy. Pfannenstial Incision: A transverse incision through the external sheath of the rectus muscles, about an inch above the pubes. It follows natural folds of the skin and curves over mons pubis in such a way that the pubic hairs cover the scar. Rocky-Davis Incision: muscle splitting transverse abdominal incision employed in appendectomy.

5.

8.

The Paramedian Incision

The paramedian incision is a vertical incision made parallel to and approximately 3 cm from the midline
Rectus - retracted laterally

The potential advantages of this incision are:

The rectus muscle is not divided The incisions in the anterior and posterior rectus sheath are separated by muscle The incision is closed in layers peritoneum and posterior sheat the anterior sheath Lower incidence of incisional hernia

Midline Incision:
The most common and most versatile approach. Closure
2 No. 1 continuous polypropolene sutures that meet in the middle Bites incorporating all layers of the abdominal wall except skin and fat - no need to close the peritoneum

Suture Characteristics
Nonabsorbable suture has better tensile strength but can persist and become a focus of infection or a draining sinus tract Monofilaments and inert materials are less likely to be associated with wound infection Braided materials knot more securely than monofilament and are less likely to stretch Memory describes a stitches tendency to straighten over time loosening and slipping. It is overcome by tying square knots and using an adequate number of throws.

Suture Techniques
One centimeter back and one centimeter apart.
Bite to prevent the suture from pulling through it should be placed at least 1 cm from the wound edge Spacing to distribute the tension on the tissues while also preventing herniation between the sutures stitches are placed about 1 cm apart Continuous vs. Interrupted Sutures continuous suturing may better distribute the tension but if one bite pulls loose it compromises the whole closure Tension Sutures Full thickness sutures that help prevent dehisance in cases of difficult abdominal closure

Prevention of Trocar Site Hernias

The incidence of trocar site hernia has been shown to be 0.65% to 2.80% midline, periumbilical port sites greater than 5 cm and made with bladed introducers often result in incisional hernia if not closed.

Port Site Closure Technique

Indications for Incisional Hernia Repair

The presence of the hernia is indication for repair in patients able to tolerate surgery. Strangulation and acute incarceration are indications for urgent operation.
Incarceration Occurs in about (6-15%) of incisional hernias Strangulation Occur in about 2% of all incisional hernias

Principles of Repair
Tension Free Repair Incision - Chosen to Provide Good Exposure of the Defect Do Not Expose Bowel to Reactive Mesh Clear Adequate Margins of the Defect Skin Hygiene Antibiotic Prophylaxis Choice of Anethesia Avoid Counter-incisions When to Excise the Sac

Direct Open Repair Pants over Vest

Direct Open Repair

Other techniques for open, primary repair include simple interrupted or continuous suturing of the fascial edges or the use of mattress, figure of eight or even internal retention sutures. Direct repair is reserved for small defects with the upper size limit cited as being between 3 and 5 cm. Even in small hernias recurrence rates of up to 50% have been reported with these techniques.

Direct Open Repair For Larger Defects

Open Onlay Mesh Repair

Open Inlay Mesh Repair

Rives-Stoppa Technique

Intraperitoneal Underlay Mesh Repair

Pascal's principlewide mesh overlap of defect distributes pressure equally over larger surface area.

Laparoscopic Repair Set Up and Trocar Sites

Laparoscopic Hernia Reduction and Adhesiolysis

Hernia contents are gently reduced using broad grasping instruments. External counter-pressure aids the reduction.

The extent of the defect is assessed.

The margins of the defect may be marked on the skin. The patch is measured and trimmed to fit. With the smooth side down, 4-6 large fixation sutures are placed around the patch and tied

Laparoscopic Mesh Insertion

Laparoscopic Mesh Fixation

A Few Mesh Materials

Vicryl (polyglactin 910) woven mesh is prepared from a synthetic absorbable copolymer of glycolide and lactide, derived respectively from glycolic and lactic acids. It is absorbable and reactive. Marlex, also known as Prolene - Polypropylene non-absorbable, non reactive monofilament. Polyester Fiber Mesh is nonabsorbable, knitted, flexible and durable. It has a high degree of porosity that allows tissue ingrowth. Polytetrafluoroethylene (PTFE) and expanded polytetrafluoroethylene (ePTFE) carbon and fluorine based synthetic polymers that are biologically inert and non-biodegradable in the body. ePTFE is more commonly known by the brand names Gore-Tex and SoftForm.

Mesh Products by Bard

Bard Composix E/X mesh is designed for laparoscopic ventral hernia repair. Its low profile makes it easy to manipulate, and its sealed edge eliminates exposed mesh along the perimeter. The Bard Composix Kugel patch has a "memory recoil ring" which helps the patch to maintain its shape during placement. The Bard Ventralex patch is designed for open repairs of defects 4 cm or less. The positioning pocket and straps facilitate placement.

Mesh Products by Ethicon

ULTRAPRO* is Partially Absorbable Mesh - the only one in the US. It culminates a natural evolution in mesh repair toward lighter, absorbable material. So it forms a flexible scar

PROCEED* Surgical Mesh also has two layers, a thin, bioresorbable layer that separates its strong, supportive mesh from underlying viscera. It is a lightweight construction to improve handeling for laparoscopic procedures. It has a special deploying tool.

Mesh Products by Gore

GORE MYCROMESH PLUS Biomaterial has antimicrobial technology. This ePTFE biomaterial contains silver carbonate and chlorhexidine diacetate, which inhibit bacterial colonization on the patch for up to 10 days postimplantation.

GORE DUALMESH is a soft, ePTFE that has two functionally distinct surfaces: a closed structure surface for reduced tissue attachment and a macroporous structure surface for faster tissue attachment

Complications of Incisional Hernia Repair

Enterotomy Respiratory Distress Wound Infection Abdominal Compartment Mesh Infection syndrome or IVC Persistent seroma compression Prolonged Pain Ileus Bleeding/Hematoma Recurrance

Algorithm For Enterotomy During Laproscopic Incisional Hernia Repair

Enterotomy
YES

Spillage?
No No

Repair and proceed

Open to repair and complete adhesolysis

Laparoscopic repair possible?

YES

No Mesh Placement. Staged repair to be completed in several days to weeks

Repair laproscopically and complete adhesolysis

Wound and Mesh Infection

Is mesh was just a large foreign body in an otherwise clean surgical wound?
many wounds are inflamed but not necessarily infected infected wounds need to be opened
avoid exposing the underlying mesh if possible

infections that involve polypropylene meshes can be managed with surgical drainage, excision of exposed, segments and antibiotics Meshes (ePTFE) require removal in most cases because they lack tissue ingrowth that could combat the infection

Seroma
The development of seroma is virtually guaranteed after lap incisional hernia repair and probably after repair with mesh in general. They typically resolve spontaneously without intervention and are not considered a complication unless they are clinically apparent more than 8 weeks postoperatively.

Complications: Prolonged Pain

In Rives-Stoppa or other open mesh implantation it occurs in more than 10% of patients Transabdominal suture site pain after laparoscopic ventral hernia repair occurs in 1% to 3% of patients.

Contraindications to Lap Incisional Hernia Repair

Major loss of abdominal domain Severe debilitation Fewer than 5 years life expectancy Respiratory distress Pregnancy Portal hypertension Renal failure with presence of peritoneal dialysis catheter

Possible Advantages of Laparoscopic Repair

Minimization of soft-tissue dissection To visualize much of the abdominal wall leads to fewer missed hernias In obese patients Recurrent hernias- Avoids dissection through the previous operative site.

Comparison studies of laparoscopic and open ventral hernia repairs

# of patients Lap
Name McGreevy [48] Raftopoulos [49] Wright [50] Robbins [51] DeMaria [36] Chari [52] Carbajo [35] Ramshaw [33] Park [23] Holzman [53] Percent Year 2003 2003 2002 2001 2000 2000 1999 1999 1998 1997 65 50 90 18 21 14 30 79 56 21 71 22 90 31 18 14 30 174 49 16 5 14 15 13 2 20 15 10 5 23.2 15 10 31 13 2 6 46 18 5 30.2 2 1 1 1 1 0 0 1 2 0 2.0 0 0 1 4 2 1 3 5 1 1 3. 5

Morbidity lap open

Mesh Infxn lap

Wound Recur infection

open

O L O L O
0 1 1 1 1 7 1 8 0 4 1 1 4 5

1 0

0 5 1 2 6 0 1 2. 6 2 2 0 5. 8 2 6 2 4. 0 36 17 2 16. 5

Comparing Laparoscopic to Open: Prospective Studies

Two prospective studies comparing laparoscopic ventral hernia repair with open:
Carbajo et al Surg Endosc. 1999 DeMaria et al Surg Endoscopy 2000 They support the advantages purported by the previous studies

A design for a prospective, randomized multicenter study organized by Dr. Itani from Harvard was published in AJS in Dec. 2004.
It is comparing laparoscopic repair with the Chevrel primary repair with mesh onlay and hypothesizes that the laparoscopic group will have fewer complications at 8 weeks post op

St Lukes-Roosevelt

References
Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg 1989;124:485-8. Bucknall TE, BMJ 1982;284:931-3 Manninen MJ, Lavonius M, Perhoniemi VJ. Results of incisional hernia repair: a retrospective study of 172 unselected hernioplasties. Eur J Surg 1991;157:29-31. Bucknall TE, Burst Abdomen and incisional hernia: a prospective study of 1129 major laparotomies. BJM 182;284:931-3. Pollack AV, Single-layer mass closure of major laparotomies by continuous suturing. J R Soc MED 1979;72:889-93 Carlson MA, Ludwig KA, Condon RE. Ventral hernia and other complications of 1,000 midline incisions. South Med J 1995;88:450-3. Mastery of Surgery Dr. Penn and Dr. Baker Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright 2002 Churchill Livingstone, Inc Nonclosure of peritoneum: a reappraisal. Tulandi T - Am J Obstet Gynecol - 01-AUG-2003; 189(2): 609-12 Tonouchi H. Ohmori Y. Kobayashi M. Kusunoki M. Trocar site hernia. [Review] [63 refs] [Journal Article. Review. Review of Reported Cases] Archives of Surgery. 139(11):1248-56, 2004 Nov. The 2-mm trocar: a safe and effective way of closing trocar sites using existing equipment.Reardon PR - J Am Coll Surg - 01-FEB-2003; 196(2): 333-6. Liu CD, McFadden DW. Am Surg 2000;66:853-4. Bowrey DJ, Blom D, Crookes PF, et al. Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication. Surg Endosc 2001;15:663.Garzotto MG, Newman RC, Cohen MS, et al. Closure of laparoscopic trocar sites using a springloaded needle. Urology 1995;45:310-2. Umbilical and epigastric hernia repair. Muschaweck U - Surg Clin North Am - 01-OCT-2003; 83(5): 1207-21

References

Luijendijk RW, Hop WC, van den Tol P, DeLange DC, Braaksma MM, Ijzermans JN, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392-8 Incisional Hernia Repair Millikan KW - Surg Clin North Am - 01-OCT-2003; 83(5): 1223-34 Toy FK, et al Prospective, Multicenter Study of Laparoscopic Ventral Hernioplasty: Surg Endos 1998; 12(7):955-9. Park, A. Laparoscopic Ventral Hernia Repair. Advances in Surgery. 2004 38-47 Laparoscopic repair of incisional hernias. Cobb WS - Surg Clin North Am - 01-FEB-2005; 85(1): 91-103, ix Complications of open groin hernia repairs.Stephenson BM - Surg Clin North Am - 01-OCT-2003; 83(5): 1255-78 DeMaria et al Laproscopic intraperitoneal PTFE patch repair of ventral hernia. Surg Endoscopy 2000 Carbajo et al Laparoscopic treatment vs Open Surgery in the solution of major incisional and ventral hernias with mesh Surg Endosc. 1999

On the Horizion?
A study by Dubay et al in the anals of surgery June 2004 shows reduced recurrance rates when abdominals incisions are treated with basic fibroblast growth factor Advances in mesh technology : those such as that decrease adhesions or those that allow or even stimulate tissue regeneration or those that have improved resistance to infection. Randomized, Prospective studies that may provide guidance in choosing the proper procedure based on patient characteristics. Innovations to help those of us on the learning curve of laparoscopy

Wound matrix deposition over time. Fibronectin and type III collagen constitute the early matrix. Type I collagen accumulates later and corresponds to the increase in wound tensile strength.

PDS Background
Indications Extended wound tensile strength required Absorption (Hydrolysis) In vivo tensile strength greater than Vicryl and Dexon Day 14: 74% of tensile strength retained Day 28: 58% of tensile strength retained Day 45: 41% of tensile strength retained Day 180: Complete Suture absorption Characteristics Less contamination of the monofilament Stiffer and more difficult to handle More expensive than Dexon or Vicryl