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Plastic mesh repair of incisional hernias
Plastic Mesh Repair of Incisional Hernias Gerald 1111. Larson, MD,’ Providence, Rhode Island Harold W. Harrower, MD, FACS, Providence, Rhode Island
Since 1968 plastic mesh has been used in the repair of particularly large and/or difficult incisional hernias. Review of our first eight years’ experience shows that the mesh is well tolerated and suggests that results, although improved since the era before the use of mesh, can be further improved by revision of the technics of insertion and fixation. Clinical Material There were fifty-three patients (‘2women, 51 men) in the present study. The youngest patient was aged twenty-one years and the oldest seventy-nine years. The mean age was 55.6 years, and approximately half the patients (26) were aged between forty and sixty years. In twenty-nine patients, the operations which gave rise to incisional hernias were in the upper abdomen: stomach (13 patients); biliary tract (10); pancreas (3); portal vein (2); and spleen (1). In seventeen patients, operations called for both upper and lower abdominal exposure: colonic surgery (8); exploration (5); vascular surgery (3); and small bowel resection (1). In four patients, the incisions were in the lower abdomen: appendectomy (3 patients) and suprapubic prostatectomy (1). One patient had a midabdominal approach for umbilical hernia, and two patients had flank approaches for renal surgery. In nineteen,patients the operative procedures which gave rise to incisional hernias were done at other institutions. The incisions in which hernias developed were: midline (25 patients); paramedian (13); subcostal(7); thoracoabFrom the Surgical Service of the Veterans Administration Hospital, Providence, Rhode Island. Repint requests shouldba addressed to Harold W. Harrower, MD. Surgical Service, VA Hospital, Davis Park, Providence, Rhode Island 02908. Presented at the Fifty-Eighth Annual Meeting of the New England Surgical Society, Portsmouth. New Hampshire, September 30-October 2, 1977. * Present address: Department of Surgery, University of Illinois Medical Center, Chicago, Illinois.
volume 135, April 1979
dominal(3); transverse (3); and flank (2). In ten patients hernias involved an incision which had been used for more than one entry. In eight patients hernias arose in areas of parallel or crossing incisions. Of the fifty-three patients in the series, thirty-six had conditions that contributed to the development of incisional herniation: prostatic obstruction (20); major wound infection (19); previous hernia in the same incision (16); obstructive lung disease (13); wound dehiscence (9); morbid obesity (4); ascites (2); and widespread abdominal malignancy (1). Twenty-four patients had more than one of these risk factors. In four patients the incisional hernia had recurred after two or more previous repairs. Twenty-eight patients had other serious conditions such as cardiac, vascular, pulmonary, renal, or metabolic disease, and twelve patients had impairment of more than one organ system.. Two thirds of the patients received a prophylactic antibiotic immediately before, during, and for three days after the operation. This group included all patients who had a history of previous wound infection. Cephalosporin or penicillin was used unless some other drug was indicated by knowledge of a previous infecting organism. Operatiue Technic. The mesh used was of knitted polypropylene (Marlex”mesh), and the suture material was of # 2 braided polyethylene (Marlex” suture). Subcutaneous tissue was freed from the fascial edge of the hernia for a distance of 4 to 5 cm. If possible, a plane was developed between the posterior surface of the musculofascial layer and the peritoneum. When necessary, the peritoneal cavity was entered and adhesions freed to develop an adequate musculofascial margin. Three methods of repair were utilized. (1) Onlay (Figure 1A) consisted of uniting the musculofascial edges, imbrieating one over the other when possible, and suturing the mesh on top as a reinforcement. (2) Subfascial placement (Figure 1B) consisted of positioning the mesh extraperitoneally beneath the musculofascial edges, which were then
559
Larson and Harrower
approximated anterior to the mesh, either to each other or to the mesh itself, to minimize the amount of mesh exposed. (3) This method (Figure 1C) was similar to subfascial placement, except that the mesh was placed intraperitoneally. Depending upon the availability of fascia and the tension required, fascial edges were overlapped, abutted, or fixed to the mesh with the least possible gap. In three patients later in the series, a strip of mesh external to the fascial layer was used as a stent over which the fixation sutures were tied. (Figure 2.) In all instances, the plastic mesh was cuffed and fixed to musculofascial structures with closely placed mattress sutures. Suction drainage was used routinely, along with a firm bulky dressing. The operations were performed by surgical residents with staff supervision. Results (Table I) (1) Onlay. There have been no recurrences in the nine patients in this group. One patient died at thirty-two months of alcoholism and pancreatitis. (2) Subfascial-Extraperitoneal Placement. Sixteen of the twenty patients in this group have had no evidence of recurrence. Two patients died, one at two and a half and one at four and a half years postoperatively, of conditions not related to surgery. One additional patient was lost to follow-up after four years. Recurrent hernias occurred in four patients. Patient 1 was a forty- six year old man who had a 7 cm defect at the confluence of a right paramedian incision (for hiatus hernia repair) and a later right subcostal incision (for cholecystectomy). After the second operation a major staphylococcus infection developed in the wound. At thirteen months, after mesh repair of the hernia, small bowel obstruction developed, and he underwent reoperation at another hospital. Although we have not been able to obtain the details of this procedure, he was said to have had a recurrence of the hernia. In any event, the results of the fourth operation were satisfactory for an additional two years. Patient 2 was a fifty-two year old woman with morbid obesity. The original hernia was a 17 cm defect in a subcostal incision for cholecystectomy. Two years after herniorrhaphy there was a large protrusion of omentum and bowel through a 7 cm defect at the midline. Repair was accomplished by fixing a second piece of mesh to the first and to a rim of midline fascia. Twenty-three months later a 3 cm defect was palpable along the lateral aspect of the original mesh repair. She died at forty-eight months of pulmonary and venous thromboembolic complications of obesity. Patient 3 was a young man with a large (13 cm) flank hernia that developed after two operations for
560
removal of renal stones. The twelfth rib was resected subperiosteally to facilitate repair with the mesh. Recovery was uneventful, but a hernia approximately half the size of the original was present three months later. At reoperation (at 25 months) the mesh was intact, but the sutures had torn through the tissues inferiorly and posteriorly. The mesh was removed and a more extensive dissection was undertaken to define the linea alba, the deep lumbar fascia, and the iliac crest. A new mesh was inserted subfascially without entering the peritoneum. There has been no recurrence in the ensuing twenty months. Patient 4 was a seventy-two year old man with chronic obstructive lung disease. He had undergone gastric surgery for duodenal ulcer four years prior to admission. Postoperatively, he developed dehiscence of his midline incision. Repair of a ventral hernia was performed three years later. He presented with a recurrent 12 cm defect extending to both costal margins. Plastic mesh repair was difficult, but convalescence was uneventful. At thirty-eight months there were two separate 3 cm defects palpable lateral to the incision line at the margin of the mesh fixation. These were not troublesome, and since he also had carcinoma of the bladder with metastases, no further treatment was advised. He died at fifty-four months. (3) Intraperitoneal Placement. There have been no recurrences in twenty-two of the twenty-four patients in this group. Three of these patients had especially large hernias and, in addition to intraperitoneal mesh, had mesh strips placed anterior to the fascia as stents over which the fixation sutures were tied. One patient had an 8 X 13 cm loss of skin as part of his herniation and required skin grafting over the mesh to complete the repair. Two patients died, one of heart disease and one of carcinoma of the lung, during the follow-up period. One patient was lost to follow-up after four and a half years. Recurrences were observed in two patients. Patient 1 was a forty-three year old man who had undergone sigmoid resection two years previously for diverticulitis. The incision was midline, and herniation developed six months after operation. The hernia was repaired surgically and recurred as a 6 X 10 cm defect. Sixteen months after mesh repair, a 4 cm defect was palpable at the superior pole of the incision. This has remained asymptomatic without further enlargement for four years. Patient 2 was a forty-four year old man who underwent portacaval shunting through a subcostal incision two years previously. He presented with ascites and a 15 cm defect. Mesh repair was satisfactory for twenty-two months, but the hernia re-
The American Journal of Surgery
Incisional Hernia Repair
F&we 2. Intraperitonsalplecetnent extrafascial mesh stent.
Figure mesh.
1. Location and method
corset. This was acceptable but often unsatisfactory therapy. One of the features we believed contributed to poor results was a tendency to underestimate the magnitude of these problems and to assign the task of repair to relatively junior house officers. During this study, mesh was used in one third to one half of the patients undergoing repair of incisional hernias. Selection of cases was on the basis of the difficulty of repair, the size of the defect, and the desire to minimize anesthesia and operating time in high risk patients. Some of the patients who had mesh repairs were those previously considered inoperable. Our findings are consistent with the reported experience of other surgeons [2-51. Compiications related to implantation of mesh are rarely serious. Serum accumulation is the most frequent complication and can be minimized by deep placement of the mesh and use of suction drainage and compression dressings. When seromas occur, they are treated by aspiration and compression; a few require drainage. The frequency of wound infection does not appear to be increased by the presence of mesh and plastic sutures. Removal of the mesh is rarely required either to control infection or to permit subsequent healing. When infection does occur, drainage and local therapy are usually effective, and antibiotics appropriate to the infecting organism are given when indicated. We believe that prophylactic antibiotic treatment
of fixation of p/as&
curred when uncontrollable ascites developed. The patient died soon afterwards of liver failure. Comments
Plastic mesh has been available since 1958. The original material was woven polyethylene, but this was replaced in 1962 by knitted polypropylene. Usher [1-31 conducted the early experimental trials of the mesh and demonstrated its clinical usefulness. We began to use mesh because our recurrence rate for the repair of incisional hernias was approximately 30 per cent, and operations were long and tedious and carried a mortality of 2 to 3 per cent. In addition, we had a number of patients who were considered inoperable because of the severity of associated medical conditions. In these patients hernias were managed by the wearing of an elastic support or
TABLE I
of p/astk mesh with an
Plastic Mesh Repair of lncislonal Hernias. Follow-Up to Tlme of Recurrence, Death, or Other Loss Interval (yr) l-3
3-5
5
All Years
0
3 (1D)
5
1
9 (ID)
1 (R)
14 (2R, 1D)
10 (lR, lD, 1L)
5
20 (4R, 20, 1L)
0.5-l
Method of Repair Onlay Subfasclal-extrapefitoneal
placement
lntraperitoneal placement All ,methods
2
9 (2R, 1D)
7 (1L)
6 (1D)
24 (2R, 2D, 1L)
3 (1R)
16 (4R, 3D)
22 (lR, lD, 2L)
12 (1D)
53 (6R, 5D, 2L)
Note: R = recurrence; D = death; L = other loss.
vohmm I%, April 1978
561
Larson and Harrower
should be employed when the operative area has been the site of previous infection or suture sinus formation. Polypropylene mesh is well tolerated and so far does not appear to degrade or lose strength in patients. Removal of mesh has not been required in any patient in the present series. We have had to remove mesh in two of thirty-nine patients in whom it was used for inguinal hernia repair. In both instances the mesh had been placed ill-advisedly with silk sutures. Within months of operation mesh is uniformly infiltrated by fibrous tissue and firmly incorporated into the abdominal wall. In four patients (none in this series) we have made new entries into the peritoneal cavity through plastic mesh and sutured the edges of the incised mesh together at the conclusion of laparotomy. All patients had had mesh placed to cover large defects in the abdominal wall. By keeping dissection directly on the inner surface of the mesh, separation of adherent viscera was not too difficult. In one patient, a young man with radiation enteritis, three successive incisions were made through the same mesh for resection or bypass of small bowel. The results in all cases have been satisfactory. When mesh cannot be covered by skin or there is early loss of skin coverage due to infection or ischemic necrosis, granulation tissue will usually grow through the mesh and furnish a satisfactory base for split thickness skin grafts [6,7]. One of the patients in this series had an exceptionally large hernia with a large skin ulcer at its apex. Mesh was placed intraperitoneally after excision of the ulcer, and the exposed mesh was subsequently well covered by two split thickness grafts. Although we were initially reluctant to use mesh in the peritoneal cavity, such placement does not seem to have any adverse effects, and we now do not hesitate when this approach appears to provide better fixation and/or to be easier or faster. In this series of fifty-three patients followed from six months to eight years, there have been six recurrences to date, a rate of 11.3 per cent. Other authors [3,4], after relatively short-term follow-up, have reported a recurrence rate of approximately 10 per cent. This represents a distinct improvement over the era before the use of mesh. There has been no mortality, a lesser morbidity, and recurrences have been less frequent, smaller, and easier to handle. Recurrences must be viewed on a cost-benefit basis for each individual case, taking into consideration the difficulty and risk of the repair, the time to recurrence, the symptoms produced, and the relationship to the patient’s overall condition. Some recurrences have
562
some elements of success. This may be particularly pertinent in a patient population composed almost exclusively of cigarette smoking males with a high proportion of hernias close to the costal margins. In our patients recurrences have usually been at the periphery of the repair where sutures pull through the musculofascial margin and allow the mesh to separate. Secondary repair can sometimes be accomplished by using the original mesh. This also is consistent with the observations of others [3,4]. Some of our recurrences might have been prevented by a wider dissection of fascial planes to allow a more solid anchoring of the mesh initially. This, of course, is contrary to the objective of performing the procedure expeditiously and with limited dissection. Usher has employed two modifications to assure better mesh fixation: (1) using two layers of mesh, one internal and one external to the fascial margin [3]; and (2) using a cuff of mesh on either side of the defect with subsequent imbrication of these cuffed layers with mattress sutures [5]. We have preferred to stay with the single layer repair, using a strip of mesh external to the fascial layer as a stent over which the fixation sutures are tied. (Figure 2.) Accepting the principle that in many cases some sort of bolster is necessary to prevent detachment of the mesh, one should remain flexible in the choice of technic until further follow-up data are available. Summary
During eight years polypropylene mesh was used in fifty-three patients for the repair of difficult incisional hernias. There was no operative mortality, and the mesh has been uniformly well tolerated. To date, recurrences have been observed in six patients (11.3 per cent), a distinct improvement over the era before mesh was used. Greater attention to the details of mesh fixation may further lower the recurrence rate. References 1. Usher FC: A new plastic prosthesis for repairing tissue defects of the chest and abdominal wall. Am J Surg 97: 629. 1959. 2. Usher FC: Hernia repair with knitted Marlexa mesh. Surg Gynecol Obstet 117: 239, 1963. 3. Usher FC: Hernia repair with Marlex@mesh. An analysis of 541 cases. Arch Surg 84: 325, 1962. 4. Jacobs E, Blaisdell FW, Hall AD: Use of knitted Marlex” mesh in the repair of ventral hernias. Am J Surg 110: 897, 1965. 5. Usher FC: Hernia repair with Marlex mesh. Hernia, 2nd edition (Nyhus LM, Condon RE, ed). Philadelphia, J. B. Lippincott, 1978. 6. Markgraf WH: Abdominal wound dehiscence. A technique for repair with MarlexO mesh. Arch Surg 105: 728, 1972. 7. Gilsdorf RB, Shea MM: Repair of massive septic abdominal wall defects with Marlex@ mesh. Am J Surg 130: 634, 1975.
The American Journal of Surgery
Incisional Hernia Repair
Discussion William R. Thompson (Providence, RI): It has taken me a number of years to arrive at the same conclusions regarding technic. For some time we were using the socalled modified Gallie repair, utilizing Marlex mesh, hut because of the high recurrence rate at the point where the Marlex strips were brought through the abdominal wall, this technic was discontinued. The most important aspect of the repair is aggression in removal of flayed and poorly vascularixed tissue, without reluctance to place the Marlex sheet intraperitoneally as described. Marlex is an inert material, and it maintains its strength forever. I have treated a patient who lost the major part of her abdominal wall as a result of severe necrotizing myofasciitis and subsequent debridement. After a long period of nutritional support and many operative procedures, a large sheet of Marlex was placed intraperitoneally with coverage with full thickness skin flaps, and the final result was excellent. Frank J. Lepreau, Jr (Westport, MA): Marlex is great, but fascia lata is still in use and many of us have employed it in almost every part of the body. I hope it does not fall into oblivion. I have used it with satisfaction for some hernia repairs. I have had one problem with it, and perhaps someone else has encountered the same situation. Since the thigh wound is liable to collect serum, a major annoyance for a few of my patients, instead of just closing the skin
volamm 188, Apfs
1878
after grafting, I put a few subcutaneous stitches here and there, making the skin adherent and avoiding an empty space. When we were doing very radical mastectomies and replacing the defect with split skin, I noticed that where I secured a bleeder on the chest wall with 000 silk tie, the graft always took, but where I stopped the bleeding by electrocautery, the graft on that area showed a tiny white spot and dropped out. H. W. Harrower (closing): Incisional hernias occur occasionally in the perineum after radical excision of the rectum. Plastic mesh can be used in the repair of such a hernia. Although most hernias can be repaired with the patient’s own tissue, the advantage of plastic mesh lies in its immediate availability and the opportunity it offers the surgeon to limit the extent of dissection and shorten the operation in poor risk patients. We worried at first that the presence of plastic mesh in the abdominal wall would make subsequent laparotomy difficult. Experience with five patients has shown that this is not so. Incisions may he made directly through the mesh and the mesh left in situ. For closure, the fascial layers into which the mesh is incorporated are brought together as a single layer with interrupted sutures of polypropylene. Junior house officers tend to underestimate the complexity of incisional hernia repairs. Supervision by senior surgeons improves their understanding of the problem and the results.
563
Since 1968 plastic mesh has been used in the repair of particularly large and/or difficult incisional hernias. Review of our first eight years’ experience shows that the mesh is well tolerated and suggests that results, although improved since the era before the use of mesh, can be further improved by revision of the technics of insertion and fixation. Clinical Material There were fifty-three patients (‘2women, 51 men) in the present study. The youngest patient was aged twenty-one years and the oldest seventy-nine years. The mean age was 55.6 years, and approximately half the patients (26) were aged between forty and sixty years. In twenty-nine patients, the operations which gave rise to incisional hernias were in the upper abdomen: stomach (13 patients); biliary tract (10); pancreas (3); portal vein (2); and spleen (1). In seventeen patients, operations called for both upper and lower abdominal exposure: colonic surgery (8); exploration (5); vascular surgery (3); and small bowel resection (1). In four patients, the incisions were in the lower abdomen: appendectomy (3 patients) and suprapubic prostatectomy (1). One patient had a midabdominal approach for umbilical hernia, and two patients had flank approaches for renal surgery. In nineteen,patients the operative procedures which gave rise to incisional hernias were done at other institutions. The incisions in which hernias developed were: midline (25 patients); paramedian (13); subcostal(7); thoracoabFrom the Surgical Service of the Veterans Administration Hospital, Providence, Rhode Island. Repint requests shouldba addressed to Harold W. Harrower, MD. Surgical Service, VA Hospital, Davis Park, Providence, Rhode Island 02908. Presented at the Fifty-Eighth Annual Meeting of the New England Surgical Society, Portsmouth. New Hampshire, September 30-October 2, 1977. * Present address: Department of Surgery, University of Illinois Medical Center, Chicago, Illinois.
volume 135, April 1979
dominal(3); transverse (3); and flank (2). In ten patients hernias involved an incision which had been used for more than one entry. In eight patients hernias arose in areas of parallel or crossing incisions. Of the fifty-three patients in the series, thirty-six had conditions that contributed to the development of incisional herniation: prostatic obstruction (20); major wound infection (19); previous hernia in the same incision (16); obstructive lung disease (13); wound dehiscence (9); morbid obesity (4); ascites (2); and widespread abdominal malignancy (1). Twenty-four patients had more than one of these risk factors. In four patients the incisional hernia had recurred after two or more previous repairs. Twenty-eight patients had other serious conditions such as cardiac, vascular, pulmonary, renal, or metabolic disease, and twelve patients had impairment of more than one organ system.. Two thirds of the patients received a prophylactic antibiotic immediately before, during, and for three days after the operation. This group included all patients who had a history of previous wound infection. Cephalosporin or penicillin was used unless some other drug was indicated by knowledge of a previous infecting organism. Operatiue Technic. The mesh used was of knitted polypropylene (Marlex”mesh), and the suture material was of # 2 braided polyethylene (Marlex” suture). Subcutaneous tissue was freed from the fascial edge of the hernia for a distance of 4 to 5 cm. If possible, a plane was developed between the posterior surface of the musculofascial layer and the peritoneum. When necessary, the peritoneal cavity was entered and adhesions freed to develop an adequate musculofascial margin. Three methods of repair were utilized. (1) Onlay (Figure 1A) consisted of uniting the musculofascial edges, imbrieating one over the other when possible, and suturing the mesh on top as a reinforcement. (2) Subfascial placement (Figure 1B) consisted of positioning the mesh extraperitoneally beneath the musculofascial edges, which were then
559
Larson and Harrower
approximated anterior to the mesh, either to each other or to the mesh itself, to minimize the amount of mesh exposed. (3) This method (Figure 1C) was similar to subfascial placement, except that the mesh was placed intraperitoneally. Depending upon the availability of fascia and the tension required, fascial edges were overlapped, abutted, or fixed to the mesh with the least possible gap. In three patients later in the series, a strip of mesh external to the fascial layer was used as a stent over which the fixation sutures were tied. (Figure 2.) In all instances, the plastic mesh was cuffed and fixed to musculofascial structures with closely placed mattress sutures. Suction drainage was used routinely, along with a firm bulky dressing. The operations were performed by surgical residents with staff supervision. Results (Table I) (1) Onlay. There have been no recurrences in the nine patients in this group. One patient died at thirty-two months of alcoholism and pancreatitis. (2) Subfascial-Extraperitoneal Placement. Sixteen of the twenty patients in this group have had no evidence of recurrence. Two patients died, one at two and a half and one at four and a half years postoperatively, of conditions not related to surgery. One additional patient was lost to follow-up after four years. Recurrent hernias occurred in four patients. Patient 1 was a forty- six year old man who had a 7 cm defect at the confluence of a right paramedian incision (for hiatus hernia repair) and a later right subcostal incision (for cholecystectomy). After the second operation a major staphylococcus infection developed in the wound. At thirteen months, after mesh repair of the hernia, small bowel obstruction developed, and he underwent reoperation at another hospital. Although we have not been able to obtain the details of this procedure, he was said to have had a recurrence of the hernia. In any event, the results of the fourth operation were satisfactory for an additional two years. Patient 2 was a fifty-two year old woman with morbid obesity. The original hernia was a 17 cm defect in a subcostal incision for cholecystectomy. Two years after herniorrhaphy there was a large protrusion of omentum and bowel through a 7 cm defect at the midline. Repair was accomplished by fixing a second piece of mesh to the first and to a rim of midline fascia. Twenty-three months later a 3 cm defect was palpable along the lateral aspect of the original mesh repair. She died at forty-eight months of pulmonary and venous thromboembolic complications of obesity. Patient 3 was a young man with a large (13 cm) flank hernia that developed after two operations for
560
removal of renal stones. The twelfth rib was resected subperiosteally to facilitate repair with the mesh. Recovery was uneventful, but a hernia approximately half the size of the original was present three months later. At reoperation (at 25 months) the mesh was intact, but the sutures had torn through the tissues inferiorly and posteriorly. The mesh was removed and a more extensive dissection was undertaken to define the linea alba, the deep lumbar fascia, and the iliac crest. A new mesh was inserted subfascially without entering the peritoneum. There has been no recurrence in the ensuing twenty months. Patient 4 was a seventy-two year old man with chronic obstructive lung disease. He had undergone gastric surgery for duodenal ulcer four years prior to admission. Postoperatively, he developed dehiscence of his midline incision. Repair of a ventral hernia was performed three years later. He presented with a recurrent 12 cm defect extending to both costal margins. Plastic mesh repair was difficult, but convalescence was uneventful. At thirty-eight months there were two separate 3 cm defects palpable lateral to the incision line at the margin of the mesh fixation. These were not troublesome, and since he also had carcinoma of the bladder with metastases, no further treatment was advised. He died at fifty-four months. (3) Intraperitoneal Placement. There have been no recurrences in twenty-two of the twenty-four patients in this group. Three of these patients had especially large hernias and, in addition to intraperitoneal mesh, had mesh strips placed anterior to the fascia as stents over which the fixation sutures were tied. One patient had an 8 X 13 cm loss of skin as part of his herniation and required skin grafting over the mesh to complete the repair. Two patients died, one of heart disease and one of carcinoma of the lung, during the follow-up period. One patient was lost to follow-up after four and a half years. Recurrences were observed in two patients. Patient 1 was a forty-three year old man who had undergone sigmoid resection two years previously for diverticulitis. The incision was midline, and herniation developed six months after operation. The hernia was repaired surgically and recurred as a 6 X 10 cm defect. Sixteen months after mesh repair, a 4 cm defect was palpable at the superior pole of the incision. This has remained asymptomatic without further enlargement for four years. Patient 2 was a forty-four year old man who underwent portacaval shunting through a subcostal incision two years previously. He presented with ascites and a 15 cm defect. Mesh repair was satisfactory for twenty-two months, but the hernia re-
The American Journal of Surgery
Incisional Hernia Repair
F&we 2. Intraperitonsalplecetnent extrafascial mesh stent.
Figure mesh.
1. Location and method
corset. This was acceptable but often unsatisfactory therapy. One of the features we believed contributed to poor results was a tendency to underestimate the magnitude of these problems and to assign the task of repair to relatively junior house officers. During this study, mesh was used in one third to one half of the patients undergoing repair of incisional hernias. Selection of cases was on the basis of the difficulty of repair, the size of the defect, and the desire to minimize anesthesia and operating time in high risk patients. Some of the patients who had mesh repairs were those previously considered inoperable. Our findings are consistent with the reported experience of other surgeons [2-51. Compiications related to implantation of mesh are rarely serious. Serum accumulation is the most frequent complication and can be minimized by deep placement of the mesh and use of suction drainage and compression dressings. When seromas occur, they are treated by aspiration and compression; a few require drainage. The frequency of wound infection does not appear to be increased by the presence of mesh and plastic sutures. Removal of the mesh is rarely required either to control infection or to permit subsequent healing. When infection does occur, drainage and local therapy are usually effective, and antibiotics appropriate to the infecting organism are given when indicated. We believe that prophylactic antibiotic treatment
of fixation of p/as&
curred when uncontrollable ascites developed. The patient died soon afterwards of liver failure. Comments
Plastic mesh has been available since 1958. The original material was woven polyethylene, but this was replaced in 1962 by knitted polypropylene. Usher [1-31 conducted the early experimental trials of the mesh and demonstrated its clinical usefulness. We began to use mesh because our recurrence rate for the repair of incisional hernias was approximately 30 per cent, and operations were long and tedious and carried a mortality of 2 to 3 per cent. In addition, we had a number of patients who were considered inoperable because of the severity of associated medical conditions. In these patients hernias were managed by the wearing of an elastic support or
TABLE I
of p/astk mesh with an
Plastic Mesh Repair of lncislonal Hernias. Follow-Up to Tlme of Recurrence, Death, or Other Loss Interval (yr) l-3
3-5
5
All Years
0
3 (1D)
5
1
9 (ID)
1 (R)
14 (2R, 1D)
10 (lR, lD, 1L)
5
20 (4R, 20, 1L)
0.5-l
Method of Repair Onlay Subfasclal-extrapefitoneal
placement
lntraperitoneal placement All ,methods
2
9 (2R, 1D)
7 (1L)
6 (1D)
24 (2R, 2D, 1L)
3 (1R)
16 (4R, 3D)
22 (lR, lD, 2L)
12 (1D)
53 (6R, 5D, 2L)
Note: R = recurrence; D = death; L = other loss.
vohmm I%, April 1978
561
Larson and Harrower
should be employed when the operative area has been the site of previous infection or suture sinus formation. Polypropylene mesh is well tolerated and so far does not appear to degrade or lose strength in patients. Removal of mesh has not been required in any patient in the present series. We have had to remove mesh in two of thirty-nine patients in whom it was used for inguinal hernia repair. In both instances the mesh had been placed ill-advisedly with silk sutures. Within months of operation mesh is uniformly infiltrated by fibrous tissue and firmly incorporated into the abdominal wall. In four patients (none in this series) we have made new entries into the peritoneal cavity through plastic mesh and sutured the edges of the incised mesh together at the conclusion of laparotomy. All patients had had mesh placed to cover large defects in the abdominal wall. By keeping dissection directly on the inner surface of the mesh, separation of adherent viscera was not too difficult. In one patient, a young man with radiation enteritis, three successive incisions were made through the same mesh for resection or bypass of small bowel. The results in all cases have been satisfactory. When mesh cannot be covered by skin or there is early loss of skin coverage due to infection or ischemic necrosis, granulation tissue will usually grow through the mesh and furnish a satisfactory base for split thickness skin grafts [6,7]. One of the patients in this series had an exceptionally large hernia with a large skin ulcer at its apex. Mesh was placed intraperitoneally after excision of the ulcer, and the exposed mesh was subsequently well covered by two split thickness grafts. Although we were initially reluctant to use mesh in the peritoneal cavity, such placement does not seem to have any adverse effects, and we now do not hesitate when this approach appears to provide better fixation and/or to be easier or faster. In this series of fifty-three patients followed from six months to eight years, there have been six recurrences to date, a rate of 11.3 per cent. Other authors [3,4], after relatively short-term follow-up, have reported a recurrence rate of approximately 10 per cent. This represents a distinct improvement over the era before the use of mesh. There has been no mortality, a lesser morbidity, and recurrences have been less frequent, smaller, and easier to handle. Recurrences must be viewed on a cost-benefit basis for each individual case, taking into consideration the difficulty and risk of the repair, the time to recurrence, the symptoms produced, and the relationship to the patient’s overall condition. Some recurrences have
562
some elements of success. This may be particularly pertinent in a patient population composed almost exclusively of cigarette smoking males with a high proportion of hernias close to the costal margins. In our patients recurrences have usually been at the periphery of the repair where sutures pull through the musculofascial margin and allow the mesh to separate. Secondary repair can sometimes be accomplished by using the original mesh. This also is consistent with the observations of others [3,4]. Some of our recurrences might have been prevented by a wider dissection of fascial planes to allow a more solid anchoring of the mesh initially. This, of course, is contrary to the objective of performing the procedure expeditiously and with limited dissection. Usher has employed two modifications to assure better mesh fixation: (1) using two layers of mesh, one internal and one external to the fascial margin [3]; and (2) using a cuff of mesh on either side of the defect with subsequent imbrication of these cuffed layers with mattress sutures [5]. We have preferred to stay with the single layer repair, using a strip of mesh external to the fascial layer as a stent over which the fixation sutures are tied. (Figure 2.) Accepting the principle that in many cases some sort of bolster is necessary to prevent detachment of the mesh, one should remain flexible in the choice of technic until further follow-up data are available. Summary
During eight years polypropylene mesh was used in fifty-three patients for the repair of difficult incisional hernias. There was no operative mortality, and the mesh has been uniformly well tolerated. To date, recurrences have been observed in six patients (11.3 per cent), a distinct improvement over the era before mesh was used. Greater attention to the details of mesh fixation may further lower the recurrence rate. References 1. Usher FC: A new plastic prosthesis for repairing tissue defects of the chest and abdominal wall. Am J Surg 97: 629. 1959. 2. Usher FC: Hernia repair with knitted Marlexa mesh. Surg Gynecol Obstet 117: 239, 1963. 3. Usher FC: Hernia repair with Marlex@mesh. An analysis of 541 cases. Arch Surg 84: 325, 1962. 4. Jacobs E, Blaisdell FW, Hall AD: Use of knitted Marlex” mesh in the repair of ventral hernias. Am J Surg 110: 897, 1965. 5. Usher FC: Hernia repair with Marlex mesh. Hernia, 2nd edition (Nyhus LM, Condon RE, ed). Philadelphia, J. B. Lippincott, 1978. 6. Markgraf WH: Abdominal wound dehiscence. A technique for repair with MarlexO mesh. Arch Surg 105: 728, 1972. 7. Gilsdorf RB, Shea MM: Repair of massive septic abdominal wall defects with Marlex@ mesh. Am J Surg 130: 634, 1975.
The American Journal of Surgery
Incisional Hernia Repair
Discussion William R. Thompson (Providence, RI): It has taken me a number of years to arrive at the same conclusions regarding technic. For some time we were using the socalled modified Gallie repair, utilizing Marlex mesh, hut because of the high recurrence rate at the point where the Marlex strips were brought through the abdominal wall, this technic was discontinued. The most important aspect of the repair is aggression in removal of flayed and poorly vascularixed tissue, without reluctance to place the Marlex sheet intraperitoneally as described. Marlex is an inert material, and it maintains its strength forever. I have treated a patient who lost the major part of her abdominal wall as a result of severe necrotizing myofasciitis and subsequent debridement. After a long period of nutritional support and many operative procedures, a large sheet of Marlex was placed intraperitoneally with coverage with full thickness skin flaps, and the final result was excellent. Frank J. Lepreau, Jr (Westport, MA): Marlex is great, but fascia lata is still in use and many of us have employed it in almost every part of the body. I hope it does not fall into oblivion. I have used it with satisfaction for some hernia repairs. I have had one problem with it, and perhaps someone else has encountered the same situation. Since the thigh wound is liable to collect serum, a major annoyance for a few of my patients, instead of just closing the skin
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after grafting, I put a few subcutaneous stitches here and there, making the skin adherent and avoiding an empty space. When we were doing very radical mastectomies and replacing the defect with split skin, I noticed that where I secured a bleeder on the chest wall with 000 silk tie, the graft always took, but where I stopped the bleeding by electrocautery, the graft on that area showed a tiny white spot and dropped out. H. W. Harrower (closing): Incisional hernias occur occasionally in the perineum after radical excision of the rectum. Plastic mesh can be used in the repair of such a hernia. Although most hernias can be repaired with the patient’s own tissue, the advantage of plastic mesh lies in its immediate availability and the opportunity it offers the surgeon to limit the extent of dissection and shorten the operation in poor risk patients. We worried at first that the presence of plastic mesh in the abdominal wall would make subsequent laparotomy difficult. Experience with five patients has shown that this is not so. Incisions may he made directly through the mesh and the mesh left in situ. For closure, the fascial layers into which the mesh is incorporated are brought together as a single layer with interrupted sutures of polypropylene. Junior house officers tend to underestimate the complexity of incisional hernia repairs. Supervision by senior surgeons improves their understanding of the problem and the results.
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