Box top closure for huge incisional hernia

lRodern Operative Technics No . 12 BOX TOP CLOSURE FOR HUGE INCISIONAL HERNIA* LESLIE V . RUSH, M .D. AND H. LOWRY RUSH, M .D. Meridian, Mississippi

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PERSISTENT ',surgical enigma is the enormous incisional hernia occasionally encountered following the midline in-

However over a period of years we have been impressed that the peritoneal sac in these cases is usually thickened, redundant and infiltrated with scar tissue in such a fashion that a tough generous membrane exists . To excise and destroy this membrane when natural tissue is so badly needed for repair of this region seemed wasteful . Furthermore, it has been constantly observed that about the periphery of the hernial opening the peritoneal sac is intimately fused with the fascia of the anterior sheath forming a dense fibrous ring . This, too, can be utilized . THE OPERATION

Figure I . The hernia ; position of patient at beginning of operation ; the incision . Figure s . (A) The large redundant sac has cision in the lower abdomen . Such a problem, been dissected free exposing its line of fusion it has been found, can usually be solved by a with the fascia at the periphery of the hernial plastic procedure utilizing the patient's own opening. For the sake of clarity the sac here tissues, locally available . Furthermore, it is has not been opened . It is simpler, however, to possible to accomplish such a repair without open the sac prior to dissection . (B) Here the serious encroachment upon the vital capacity sac has been opened exposing adherent bowel . of the abdominal space . The sac is cleansed of fatty tissue as thoroughly The general approach to the problem in the as possible . past has been to force a closure of the defect Figure 3 . (A) At this stage the panniculus (as one would attempt to button a very tight adiposus has been freed from the anterior vest) by lateral overlapping of two fascial surface of the fascia for a considerable distance . An incision is being made in the posterior layers, with excision of the peritoneal sac . In contradistinction to such an approach, in sheath of the rectus . The incision is just posthis procedure the peritoneal sac is utilized to terior and peripheral to the line of fusion of the give substance to four flaps which are ad- peritoneum to the anterior fascia. The incision vanced diagonally to cover the defect, just as is continued paralleling this line of fusion until the end of a pasteboard box is closed by four the circle is complete, exposing the rectus overlapping flaps . muscle on each side . (B) The parietal periOn first thought one would doubt the ability toneum has been overlapped and sutured . of the peritoneum to play an effective rule in The rectus muscles exposed . The two lateral such a drama. And, indeed, in rare instances flaps (peritonea[ sac and fascia) are being it is too thin to be of practical use . sectioned transversely to create four flaps . Note * From the Department of Surgery, Rush Memorial Hospital, Meridian, Miss .

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American Journal of Surgery

Rush, Rush-Box Top Closure for Incisional Hernia

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April, 1953

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Rush, Rush-Box Top Closure for Incisional Hernia

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that the incision is carried laterally into the fascia for some distance beyond the hernial margin . The fascia is also incised vertically for i inch at the proximal and distal extremities of the opening . These flaps clockwise are 12-3, 3 6, 6-9 and 9-12, respectively . Figure 4 . Position of patient is now changed to semi-sitting posture . This narrows the vertical diameter of the hernial opening . Recapitulation . The steps taken up to this point are as follows : (i) The sac has been freed and cleansed ; (2) the fascia has been freed and cleansed ; (3) the peritoneal sac has been preserved, left attached to and continuous with the fascia ; (4) the parietal peritoneum has been freed, advanced and sutured in the midline ; and (5) the two flaps have been quartered by crucial incisions extending peripherally well into the fascia . We are now ready

to begin closure of the opening by advancing flap 3-6 diagonally upward across the center of the opening. Figure 5. (A) The 3-6 flap is advanced diagonally, upward and across the opening to be sutured peripherally beneath the 9- 12 flap . (B) The 9-12 flap is brought diagonally downward and sutured peripherally over the 3-6 flap . (C) The 6-9 flap has been advanced diagonally and sutured . (D) With the diagonal overlapping of flap 1-3 the closure of the defect has been completed . It will be noted that the suture of each flap as it is advanced progressively narrows the original opening and progressively lessens suture tension on those flaps which were previously advanced . Figure 6. The operation completed . Temporary latex drains arc used to carry away blood serum . American Journal of Surgery

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COMMENTS

The technic as shown is basic . It must be modified at times to fit the individual case . It may he found that in certain instances only a portion of the sac can be utilized in this manner because of thinness of the sac in certain areas . We do not know the ultimate fate of the peritoneum transplanted in the flaps . It evidently acts as a free graft which is eventually converted into fibrous tissue . Such closure in ten cases of very large hernia has resulted in rapid healing with a firm abdominal wall . n}' An x-flap plastic procedure is presented which affords a satisfactory closure of huge midline incisional hernia with the patient's own tissue, locally available . Advantages in reconstruction are gained by : (i) preserving and utilizing the peritoneal sac ; Fm . 6 . (2) preserving the line of fusion of sac to fascia ; (3) Reducing the opening by position of the strength is needed ; (6) suture of each of four patient (jack knifing) ; (4) reducing the opening flaps progressively reduces opening, and by utilizing natural cleavage planes, i .e ., multiplicity of sutures progressively relieves diagonal advancement of flaps ; (g) four flaps suture tension ; (7) broad surfaces of tissue instead of traditional two thicken wall where contact give strength and stability to closure . SUMMA

April, ty53