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Repair of recurrent ventral hernias by an internal “binder”
MODERN OPERATIVE TECHNICS
Repair of Recurrent Ventral Hernias by an Internal “Binder” Irving L. Uchtenstein, MD, Los Angeles, California J. Manny Shore, MD, Los Angeles, California
I suspect it is fair to say that graduates of many surgical residency programs today have a better understanding of the principles and techniques of gastrectomy or cholecystectomy than they do of inguinal herniorrhaphy, let alone of ventral herniorrhaphy.-M. M. Ravitch
The increasing complexity and ever-widening spectrum of surgery has generated inherent postoperative complications. One of the most challenging of these is the recurrent massive incisional hernia. Until recently, these huge ventral defects defied cure by existing surgical technics. Physiology of Ventral Hernia Repair
In 1898, William Mayo first described the imbrication operation often referred to as “vest over pants technic.” (Figure 1.) The improved results with this method are attributable to the introduction of the transverse repair rather than the use of imbrication. Overlapping of tissue per se increases suture line tension and encourages the surgeon to use weak scar tissue in order to effect wound closure [1,2]. Before Mayo’s description the vertical repair in vogue commonly failed for two reasons. (1) Since sutures are placed parallel to the direction of the aponeurotic fibers, tension causes tissue splitting, thus decreasing suture-holding power. (2) Increased intra-abdominal pressure on a vertical repair tends to distract the hernial margins since the lines of force are transverse and the fibers have been divided rather than separated. Conversely, with transverse closure, sutures are placed perpendicular to the direction of the fibers, and abdominal tension approximates the wound edges. (Figure 2.) Whenever technically feasible, therefore, transverse repair without imbrication is the preferred method for the management of large ventral hernias. From the Lbpamnent of Svgery, Cedars of Lebanon--Mount Sinai Medical Center, Los Angeles, California. Reprint requests should be addressed to Irving I_. khtenstein. MD. 9201 Sunset Boulevard, Los Angeles. California 90069.
Votume 132, July 1076
Technic
When the defect is small, secure closure is readily accomplished by simple marginal approximation of healthy aponeurotic tissue. (Figure 3.) With the use of strong interrupted, nonabsorbable sutures, a “one layer” closure suffices. This includes peritoneum and the fused rectus sheaths. The repair may be buttressed by tacking a plastic screen over the suture line. (Figure 4.) Attempts at primary closure should be abandoned if this can only be accomplished with attenuated fascia or cicatrix. Here, alternative methods of reconstruction must be employed. Local anesthesia is adequate for the average small ventral hernia and permits intraoperative testing of the repair. The value of this concept has been previously described in the management of groin hernias [3]. For large incisional hernias, a “differential” epidural block is preferred. (Figure 5.) This anesthetic technic blocks sensory fibers while preserving motor function. A unique opportunity is thus provided to
Figure 1. Vertkal closure of hernia wfth hnbrkathm Rewifh perm&Won of pu6ffsfwr from [O1.
phted
121
Lichtenstein and Shore
A
.
B
._-.
c l”.-.l,
j”““.“_^_-.-.._
F&we 2. Transverseciosure versus vertkai repair. A, transverse versus vertkalinckkn. 6, pthathm of/xbers In transverse repair. C, intra-abdominal tenskn separa& ed#es of vetikai inciskn. D, shearing or splittl~ of fibers in vertkai mpair. (Rep&ted with permlsskn of publisher from [9]; radra wn from Kozoii DD: incisknai hemta. Hernia (Nyhus ur, HaMas HN, ad). Wiadem, JB L@incott, 7#64.)
“, ““_...^__.
F@re 3. Transversecksure of Incfsionaihemta [9 ].
Figure 4. Screen r&S
122
of vM/cai cbslm
[9 1.
F&ura 5. The thumb exe* pressure on the ptunger until a suddsndistkot kas of resistanoe indkates the needk tip k in the epkfurai spaoe. (RaprinM with permfsskn of pub&her from [9]; rsdrawn t&m Msora DC: Regknai Block, 2nd ad. SiMngfietd, Charles C. lWmas, 1957.)
nleAmwkanJoumalot~ry
Flpre 6. Omentai adhesions in a multltoculated inclslonal hernia. (Reprlnted wtth permtssion of pubUsher from [9]; redrawn from Zimmerman,. Ansan: An@nny and Surgery of Hernia. 8althnore, Wlllams and Wilkins, 1967.)
test the integrity of the repair during the operation by having the patient perform the valsalva maneuver. This essential step is not possible with spinal or general anesthesia. Since incisional hernias are frequently multilocular, the subcutaneous dissection is extended until healthy aponeurotic margins are exposed. (Figure 6.) Radical debridement of all attenuated fascia or scar tissue is mandatory, regardless of the size of the resulting defect. When closure cannot be accomplished without tension, a prosthetic screen is used to bridge the opening. This concept, employing fascia lam, was first introduced by Gallie [4] and later modified by Burton [5] and Knight and Brown [6]. Use of polypropylene mesh, which is strong, monofilamented, pliable, and resistant to infection, avoids the additional surgery necessary to obtain a fascial graft [ 71. Furthermore, the screen stimulates the formation of dense fibrous tissue which infiltrates the interstices and permanently reinforces the repair. The presence of the mesh in direct contact with the abdominal viscera has given rise to no complications. The prosthesis is fashioned to resemble a scultetus binder. (Figure 7.) A sheet of mesh is employed which is 15 cm longer and wider than the defect. A series of 2 cm paraliel strips are cut from each side, leaving an intact central bridge of varying size depending on the diameter of the defect. The screen is inserted sub-
Volume X%2,July 1976
Figure 7. The piypropyle~
“binder” [6 ].
peritoneally. With use of a Gallie fascial needle, the tails are brought out through the aponeurotic layer under sufficient traction to avoid buckling. (Figure 8.) Each strip is anchored with a single nonabsorbable suture. (Figure 9.) Marginal approximation may be facilitated by tying of the tails over the defect. This, however, produces large buried knots, increases the possibility of seroma, may invite herniation at the strip exit sites, and adds nothing to the strength of this repair. Moreover, crossing the tails is unnecessary since it is often possible to close or reduce the size of even large defects by simple insertion of the prosthesis, because anchoring the stretched mesh decreases wound tension. When the edges of the defect cannot be approximated (Figure lo), an additional reinforcing screen may be placed anterior to the apo-
123
Lichtenstein and Shore
neurosis, thereby patching the remaining gap with an onlay mesh graft. After the “binder” is secured, the integrity of the repair is tested. Upon request, intra-abdominal pressure is forcibly increased by voluntary cough, valsalva maneuver, and elevation of the shoulders from the operating table [B].
Figure 8. The drawing demonstrates the abt/ity of the prosthesis to reconstruct the abdominal wall by bridging the fascial defect [Q].
neurotic wall Smen
These maneuvers apply a measurable strain to the herniorrhaphy equivalent to vigorous physical activity. This establishes that the repair is functionally adequate to withstand unrestricted postoperative activity without inviting recurrence [9]. Experimental studies in our laboratory and elsewhere have shown that wound strength is not de-
Figure 9. In the artist’s rendition, the wound edges can be approxtma ted [ 9 ] -
Peritone \ ..._ .---.-..__._.__A_
Figure 10. A, cross section of repair when hernbl defect cannot be closed. B, in this illustratlon the wound edges are approximated and the repair is reinforced wfth a second screen [Q].
124
The American Journal ol Surgery
Ventral Hernia Repair
pendent on the healing process; rather, it is derived from strong tissue united with unbreakable sutures [I]. Extensive experience with this principle in the management of groin hernias has verified the validity of this concept. The wound is sprayed with an aerosol mixture of neomycin, bacitracin, and polymixin. Because these antibiotics are never used systemically, they offer safe, broad spectrum prophylaxis [IO]. Despite extensive dissection and the presence of mesh, the wound is usually not drained, since serous fluid passes through the screen into the peritoneal cavity where it is rapidly absorbed.
Results
Thirty-nine patients have undergone repair of massive recurrent incisional hernias by the intraperitoneal “binder” technic. Eleven of these patients have been operated on within the past twelve months. There have been no recurrences in the remaining twenty-eight patients followed for one to ten years. Despite the history of prior wound infection in the majority of these patients, sepsis was encountered only once in this series. In six additional patients, repeated aspiration was necessary to drain wound seromas. Postoperative draining sinuses were not observed and in no instance was mesh removal required.
Volume 192, July 1976
Summary
A technic for the repair of massive recurrent incisional hernia is described. Use of a polypropylene mesh prosthesis as an intraperitoneal “binder” permits reconstruction of the abdominal wall when primary closure is impossible. Intraoperative testing of the repair provides reassurance that unrestricted postoperative activity will not invite recurrence. References 1. Lichtenstein IL, Herzikoff S, Shore JM, Jiron MW, Stuart S, Mizuno L: The dynamics of wound healing. Surg Gynecol O&ret 130: 685, 1970. 2. Farris JM, Smith GK, Beattie AS: Umbilical hernia: an inquiry into the principle of imbrication and a note on the preservation of the umbilical dimple. Am J Surg 98: 236, 1959. 3. Engel HL: Differential epidural block; p 56. Hernia Repair without Disability (Lichtenstein, IL, ed). St. Louis, CV Mosby, 1970. 4. Gallie WE: Closing very large hernial openings. Ann Surg 96: 551,1932. 5. Burton CC: Fascia lata, cutis, and tantalum grafts in repair of massive abdominal incisional hernias. Surg Gynecol G&ret 109: 621, 1959. 6. Knight IA, Brown G: The repair of large incisional hernias. Calif Med 108: 96, 1968. 7. Uher FC, Ochsner J, Tuttle LLD Jr: Use of Marlex mesh in the repair of incisional hernias. Am Surg 24: 969, 1958. 8. Lichtenstein IL: Immediate ambulation and return to work following herniorrhaphy. lndustr h&d Surg 35: 754, 1966. 9. Lichtenstein IL: Hernia repair without disability. Hernia Repair without Disability (Lichtenstein L, ed). St. Louis, CV Mosby, 1970. 10. Lichtenstein IL, Shore JM: Simplified repair of femoral and recurrent inguinal hernias by a “plug” technic. Am J Surg 439: 128, 1974.
125
Repair of Recurrent Ventral Hernias by an Internal “Binder” Irving L. Uchtenstein, MD, Los Angeles, California J. Manny Shore, MD, Los Angeles, California
I suspect it is fair to say that graduates of many surgical residency programs today have a better understanding of the principles and techniques of gastrectomy or cholecystectomy than they do of inguinal herniorrhaphy, let alone of ventral herniorrhaphy.-M. M. Ravitch
The increasing complexity and ever-widening spectrum of surgery has generated inherent postoperative complications. One of the most challenging of these is the recurrent massive incisional hernia. Until recently, these huge ventral defects defied cure by existing surgical technics. Physiology of Ventral Hernia Repair
In 1898, William Mayo first described the imbrication operation often referred to as “vest over pants technic.” (Figure 1.) The improved results with this method are attributable to the introduction of the transverse repair rather than the use of imbrication. Overlapping of tissue per se increases suture line tension and encourages the surgeon to use weak scar tissue in order to effect wound closure [1,2]. Before Mayo’s description the vertical repair in vogue commonly failed for two reasons. (1) Since sutures are placed parallel to the direction of the aponeurotic fibers, tension causes tissue splitting, thus decreasing suture-holding power. (2) Increased intra-abdominal pressure on a vertical repair tends to distract the hernial margins since the lines of force are transverse and the fibers have been divided rather than separated. Conversely, with transverse closure, sutures are placed perpendicular to the direction of the fibers, and abdominal tension approximates the wound edges. (Figure 2.) Whenever technically feasible, therefore, transverse repair without imbrication is the preferred method for the management of large ventral hernias. From the Lbpamnent of Svgery, Cedars of Lebanon--Mount Sinai Medical Center, Los Angeles, California. Reprint requests should be addressed to Irving I_. khtenstein. MD. 9201 Sunset Boulevard, Los Angeles. California 90069.
Votume 132, July 1076
Technic
When the defect is small, secure closure is readily accomplished by simple marginal approximation of healthy aponeurotic tissue. (Figure 3.) With the use of strong interrupted, nonabsorbable sutures, a “one layer” closure suffices. This includes peritoneum and the fused rectus sheaths. The repair may be buttressed by tacking a plastic screen over the suture line. (Figure 4.) Attempts at primary closure should be abandoned if this can only be accomplished with attenuated fascia or cicatrix. Here, alternative methods of reconstruction must be employed. Local anesthesia is adequate for the average small ventral hernia and permits intraoperative testing of the repair. The value of this concept has been previously described in the management of groin hernias [3]. For large incisional hernias, a “differential” epidural block is preferred. (Figure 5.) This anesthetic technic blocks sensory fibers while preserving motor function. A unique opportunity is thus provided to
Figure 1. Vertkal closure of hernia wfth hnbrkathm Rewifh perm&Won of pu6ffsfwr from [O1.
phted
121
Lichtenstein and Shore
A
.
B
._-.
c l”.-.l,
j”““.“_^_-.-.._
F&we 2. Transverseciosure versus vertkai repair. A, transverse versus vertkalinckkn. 6, pthathm of/xbers In transverse repair. C, intra-abdominal tenskn separa& ed#es of vetikai inciskn. D, shearing or splittl~ of fibers in vertkai mpair. (Rep&ted with permlsskn of publisher from [9]; radra wn from Kozoii DD: incisknai hemta. Hernia (Nyhus ur, HaMas HN, ad). Wiadem, JB L@incott, 7#64.)
“, ““_...^__.
F@re 3. Transversecksure of Incfsionaihemta [9 ].
Figure 4. Screen r&S
122
of vM/cai cbslm
[9 1.
F&ura 5. The thumb exe* pressure on the ptunger until a suddsndistkot kas of resistanoe indkates the needk tip k in the epkfurai spaoe. (RaprinM with permfsskn of pub&her from [9]; rsdrawn t&m Msora DC: Regknai Block, 2nd ad. SiMngfietd, Charles C. lWmas, 1957.)
nleAmwkanJoumalot~ry
Flpre 6. Omentai adhesions in a multltoculated inclslonal hernia. (Reprlnted wtth permtssion of pubUsher from [9]; redrawn from Zimmerman,. Ansan: An@nny and Surgery of Hernia. 8althnore, Wlllams and Wilkins, 1967.)
test the integrity of the repair during the operation by having the patient perform the valsalva maneuver. This essential step is not possible with spinal or general anesthesia. Since incisional hernias are frequently multilocular, the subcutaneous dissection is extended until healthy aponeurotic margins are exposed. (Figure 6.) Radical debridement of all attenuated fascia or scar tissue is mandatory, regardless of the size of the resulting defect. When closure cannot be accomplished without tension, a prosthetic screen is used to bridge the opening. This concept, employing fascia lam, was first introduced by Gallie [4] and later modified by Burton [5] and Knight and Brown [6]. Use of polypropylene mesh, which is strong, monofilamented, pliable, and resistant to infection, avoids the additional surgery necessary to obtain a fascial graft [ 71. Furthermore, the screen stimulates the formation of dense fibrous tissue which infiltrates the interstices and permanently reinforces the repair. The presence of the mesh in direct contact with the abdominal viscera has given rise to no complications. The prosthesis is fashioned to resemble a scultetus binder. (Figure 7.) A sheet of mesh is employed which is 15 cm longer and wider than the defect. A series of 2 cm paraliel strips are cut from each side, leaving an intact central bridge of varying size depending on the diameter of the defect. The screen is inserted sub-
Volume X%2,July 1976
Figure 7. The piypropyle~
“binder” [6 ].
peritoneally. With use of a Gallie fascial needle, the tails are brought out through the aponeurotic layer under sufficient traction to avoid buckling. (Figure 8.) Each strip is anchored with a single nonabsorbable suture. (Figure 9.) Marginal approximation may be facilitated by tying of the tails over the defect. This, however, produces large buried knots, increases the possibility of seroma, may invite herniation at the strip exit sites, and adds nothing to the strength of this repair. Moreover, crossing the tails is unnecessary since it is often possible to close or reduce the size of even large defects by simple insertion of the prosthesis, because anchoring the stretched mesh decreases wound tension. When the edges of the defect cannot be approximated (Figure lo), an additional reinforcing screen may be placed anterior to the apo-
123
Lichtenstein and Shore
neurosis, thereby patching the remaining gap with an onlay mesh graft. After the “binder” is secured, the integrity of the repair is tested. Upon request, intra-abdominal pressure is forcibly increased by voluntary cough, valsalva maneuver, and elevation of the shoulders from the operating table [B].
Figure 8. The drawing demonstrates the abt/ity of the prosthesis to reconstruct the abdominal wall by bridging the fascial defect [Q].
neurotic wall Smen
These maneuvers apply a measurable strain to the herniorrhaphy equivalent to vigorous physical activity. This establishes that the repair is functionally adequate to withstand unrestricted postoperative activity without inviting recurrence [9]. Experimental studies in our laboratory and elsewhere have shown that wound strength is not de-
Figure 9. In the artist’s rendition, the wound edges can be approxtma ted [ 9 ] -
Peritone \ ..._ .---.-..__._.__A_
Figure 10. A, cross section of repair when hernbl defect cannot be closed. B, in this illustratlon the wound edges are approximated and the repair is reinforced wfth a second screen [Q].
124
The American Journal ol Surgery
Ventral Hernia Repair
pendent on the healing process; rather, it is derived from strong tissue united with unbreakable sutures [I]. Extensive experience with this principle in the management of groin hernias has verified the validity of this concept. The wound is sprayed with an aerosol mixture of neomycin, bacitracin, and polymixin. Because these antibiotics are never used systemically, they offer safe, broad spectrum prophylaxis [IO]. Despite extensive dissection and the presence of mesh, the wound is usually not drained, since serous fluid passes through the screen into the peritoneal cavity where it is rapidly absorbed.
Results
Thirty-nine patients have undergone repair of massive recurrent incisional hernias by the intraperitoneal “binder” technic. Eleven of these patients have been operated on within the past twelve months. There have been no recurrences in the remaining twenty-eight patients followed for one to ten years. Despite the history of prior wound infection in the majority of these patients, sepsis was encountered only once in this series. In six additional patients, repeated aspiration was necessary to drain wound seromas. Postoperative draining sinuses were not observed and in no instance was mesh removal required.
Volume 192, July 1976
Summary
A technic for the repair of massive recurrent incisional hernia is described. Use of a polypropylene mesh prosthesis as an intraperitoneal “binder” permits reconstruction of the abdominal wall when primary closure is impossible. Intraoperative testing of the repair provides reassurance that unrestricted postoperative activity will not invite recurrence. References 1. Lichtenstein IL, Herzikoff S, Shore JM, Jiron MW, Stuart S, Mizuno L: The dynamics of wound healing. Surg Gynecol O&ret 130: 685, 1970. 2. Farris JM, Smith GK, Beattie AS: Umbilical hernia: an inquiry into the principle of imbrication and a note on the preservation of the umbilical dimple. Am J Surg 98: 236, 1959. 3. Engel HL: Differential epidural block; p 56. Hernia Repair without Disability (Lichtenstein, IL, ed). St. Louis, CV Mosby, 1970. 4. Gallie WE: Closing very large hernial openings. Ann Surg 96: 551,1932. 5. Burton CC: Fascia lata, cutis, and tantalum grafts in repair of massive abdominal incisional hernias. Surg Gynecol G&ret 109: 621, 1959. 6. Knight IA, Brown G: The repair of large incisional hernias. Calif Med 108: 96, 1968. 7. Uher FC, Ochsner J, Tuttle LLD Jr: Use of Marlex mesh in the repair of incisional hernias. Am Surg 24: 969, 1958. 8. Lichtenstein IL: Immediate ambulation and return to work following herniorrhaphy. lndustr h&d Surg 35: 754, 1966. 9. Lichtenstein IL: Hernia repair without disability. Hernia Repair without Disability (Lichtenstein L, ed). St. Louis, CV Mosby, 1970. 10. Lichtenstein IL, Shore JM: Simplified repair of femoral and recurrent inguinal hernias by a “plug” technic. Am J Surg 439: 128, 1974.
125