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Repair of Incisional Hernia
REPAIR OF INCISIONAL HERNIA RICHARD
B.
CATTELL
Incisional or ventral hernia is a frequent late complication of abdominal surgery. It is usually the result of partial disruption of the fascial layer followed by an opening in the peritoneal layer. Unless actual eventration occurs it may not be recognized during the immediate postoperative period. It is usually the result of a wound complication such as bleeding or infection in the abdominal wall. If partial disruption can be recognized during the postoperative period by discharge of blood or serosanguinous fluid from the wound later hernia can usually be avoided if immediate secondary closure of the wound is accomplished. Incisional hernia most often occurs in obese individuals and is particularly prevalent when there has been a postoperative pulmonary complication. It is also common when abdominal surgery has been undertaken for malignant disease in debilitated and poorly nourished patients. With better selection of the abdominal incision, the incidence can be decreased. The employment of transverse incisions and those which avoid cutting more than one or two nerves likewise will result in a stronger abdominal incisional scar. The repair of large incisional hernias may be quite difficult by any type of procedure, particularly those with large defects of the abdominal wall. The use of nonabsorbable sutures in effecting the repair, and the use of fresh fascia as described by Gallie have given improved results. Alloy steel wire has been effectively utilized by Babcock and others to effect the repair. In large defects Koontz has described the use of large squares of tantalum mesh. In 1942, I described a simplified technic for repair of large incisional hernias which was found quite priLCtical. It has now been employed over a period of ten years with good results. Patients who have large incisional hernias are frequently poor risks either because of obesity or because of cardiovascular or renal conditions. Because of the frequency of postoperative complications in this group of patients they should be very carefully studied previous to advising operation. Pulmonary complications and thrombophlebitis may follow repair but can usually be avoided. Obese patients should be put on a strict reduction diet and repair should be delayed whenever possible until their weight falls within a normal range. Because of the marked changes in intra-abdominal pressure produced by the repair, it is well during the period of preparation to have them fitted with an abdominal belt to 787
788
RICHARD B. CATTELL
reduce the contents of the hernia as far as possible within the abdominal cavity. In some patients, because of marked disability or abdominal pain, operation must be advised before weight reduction. Likewise, when incarceration is present with threatened or impending strangulation of the contents of the sac, operation must be carried out at a less advantageous time. With large hernias, at times the skin becomes ulcerated because of excessive pressure, and immediate operation should then be advised. Under these circumstances the technic which will be described is particularly applicable since it can be carried out with a minimum of technical difficulties even in very obese patients. The usual technic employed for the repair of incisional hernia includes isolation of the sac and its contents, following which the layers of the abdominal wall are dissected out separately. This is frequently a long and tedious dissection and even when carried out in the best manner possible it may result in obtaining quite weak layers that are not easily sutured owing to their irregularity and weakness. The chief difference in the conventional method of hernia repair and the plan which will be described is that the strong layer of the ring is not disturbed. This ring consists of fragments of the peritoneum, muscle and fascia and, in the upper abdomen, portions of the posterior rectus sheath and transversalis muscle. The layers of the abdominal wall are identified ' subsequently during the repair at some distance from the ring. TECHNIC
. After applying traction to the previous incisional scar, an elliptical incision is made around the scar incorporating the excess skin of the abdominal wall (Fig. 295, a). By firm traction, the contents of the sac will usually fall away. The incision is then continued outward through the layer of fat until the fascia is encountered (Fig. 295, b). These lateral flaps are freed up for a considerable distance laterally beyond the ring of defect, leaving a broad surface of fascia exposed. It is a relatively bloodless procedure. Traction is maintained on the sac and sharp dissection is carried out medially around the entire neck of the sac at its junction with the fascia (Fig. 295, b). When a wide dissection of the flap has been carried out, the skin is incised over the sac, which is entered. The abdominal contents are completely freed from the sac and the dissection carried out well beneath the abdominal wall for the full circumference of the defect. It is frequently advisable to excise large portions of omentum. The skin is excised from the sac, and the fat cut away from its entire surface (Fig. 296, a). With the defect of the abdominal wall outlined, the peritoneum is approximated in a longitudinal direction with a continuous heavy
REPAIR OF INCISIONAL HEHNIA
789
chromic interlocking suture, including all layers of the abdominal wall that are attached to the hernial ring (Fig. 296, b). This can be accomplished even when large defects are present.
Fig. 295.-a, The outline of the hernia is shown. An elliptical incision has been made enclosing the scar and excess skin. b, Lateral flaps have been freed, exposing the fascia. The dissection is then carried medially to expose the edge of the defect in the abdominal wall.
The large redundancy of sac is cut away at a distance of 2 cm. from the previous suture line. This redundant portion of the sac, again con-
790
HICHAHD B. CATTELL
taining portions of peritoneum, muscle and fascia, is approximated with interrupted or continuous chromic sutures immediately overlying the
NECK OF SAC CLOSED
Fig. 296.-a, The sac is opened and the contents freed and reduced. The skin and fat are dissected from thc peritoneal sac. b, Closure of the hernia defect from the inside of the sac. Dotted line shows the line of removal of excess sac.
first suture line (Fig. 297, a). In some patients with large defects these two layers are closed by means of alloy steel wire and the operation is concluded with this simple repair. This is effective in the upper part of
REPAIR OF INCISIONAL HERNIA
791
the abdomen if the previous incision has been made in the linea alba or midline. At times it is sufficient in lower midline incisions as well. It is
a
llil" SUTURE LINE (NECK OF SAC)
Fig. 297.--a, The remaining free edge is sutured. The dotted line shows the position of the fascial incision. b, The medial borders of the fascial layer are approximated. The muscle has been expo~ed.
recommended, however, that a further layer closure be effected, as will be described. An elliptical incision is made at a distance of 2 cm. on each side lateral to the previous suture line in a position as indicated by the dotted line in
792
RICHARD B. CATTELL
Figure 297, a. This exposes the muscle on either side, which may be freed up to any extent desired. The medial borders of the elliptical incision are approximated as the third layer, as indicated in Figure 297, b. The fascial layers are freed up for a considerable distance from the muscle and interrupted sutures are used to approximate the fascia at the upper and lower angles of the incision. This is done to take the tension off the muscle. Muscle sutures are then alternated with fascial sutures until the fourth and fifth layers are completed (Fig. 298). If the fascia approximates with too great tension, the lateral flaps of the incision, including skin and fat, are elevated and counterincisions in the fascia
Fig. 298.-Alternating sutures are taken to approximate muscle and fascia.
are made at some distance laterally. No attempt is made to close the lateral defect. Following the closure of the five layers, the fat and skin are separately sutured. Drainage of the wound is optional and is rarely used except to drain the fatty layer. COMMENT
During the immediate postoperative period, full adhesive strapping to the abdomen is kept in place. Deep breathing exercises are encouraged, as is light coughing. With the abdominal support of a binder, early ambula-
REPAIH 01<' INCISIONAL HERNIA
793
tion is encouraged. We prefer to have the patients remain in bed for two days since all are operated on under pontocaine spinal anesthesia and headaches are avoided if ambulation is begun on the third day. Ace bandages are applied to the legs and leg exercises are carried out at frequent intervals during bed rest. Prophylactic use of dicumarol may be indicated. Patients are discharged from the hospital usually in ten to fourteen days, with a well-fitted canvas abdominal belt. Obese patients are given a low calorie diet and are advised to avoid gaining weight. This plan for the repair of incisional hernia has been used in a large group of patients during the past ten years with very good results. The simplicity of the procedure, which can he carried out rapidly and without an involved dissection, possesses great advantages for the type of patient who has a large incisional hernia. The procedure is equally applicable to hernias located in the upper abdomen, both in the median line and through the vertical incision through the rectus muscle. It has been used more often in lower midline incisions and for low right rectus incisional hernias. The same principle has been employed in hernias of all sizes in all quadrants of the abdomen. In our experience, repair effected by this method is followed by a very low incidence of complications and recurrences.
SUMMARY A technic for the repair of incisional hernia has been presented which is applicable to most incisional hernias irrespective of size. It has been carried out frequently in very obese patients when, because of complications, reduction of weight has been inadvisable. The chief difference between this method of repair and the one generally employed is that the repair is carried out after dealing with the sac and its contents without separate dissection of the layers of the abdominal wall. The hernial ring is approximated, following which the layers are identified and approximated over this preliminary closure.
REFERENCE 1. Cattell, R. B.: An unusual technic for the repair of incisional hernia. S. CLIN . AMERICA :11:11:795-799 (June) 194~.
NORTH
B.
CATTELL
Incisional or ventral hernia is a frequent late complication of abdominal surgery. It is usually the result of partial disruption of the fascial layer followed by an opening in the peritoneal layer. Unless actual eventration occurs it may not be recognized during the immediate postoperative period. It is usually the result of a wound complication such as bleeding or infection in the abdominal wall. If partial disruption can be recognized during the postoperative period by discharge of blood or serosanguinous fluid from the wound later hernia can usually be avoided if immediate secondary closure of the wound is accomplished. Incisional hernia most often occurs in obese individuals and is particularly prevalent when there has been a postoperative pulmonary complication. It is also common when abdominal surgery has been undertaken for malignant disease in debilitated and poorly nourished patients. With better selection of the abdominal incision, the incidence can be decreased. The employment of transverse incisions and those which avoid cutting more than one or two nerves likewise will result in a stronger abdominal incisional scar. The repair of large incisional hernias may be quite difficult by any type of procedure, particularly those with large defects of the abdominal wall. The use of nonabsorbable sutures in effecting the repair, and the use of fresh fascia as described by Gallie have given improved results. Alloy steel wire has been effectively utilized by Babcock and others to effect the repair. In large defects Koontz has described the use of large squares of tantalum mesh. In 1942, I described a simplified technic for repair of large incisional hernias which was found quite priLCtical. It has now been employed over a period of ten years with good results. Patients who have large incisional hernias are frequently poor risks either because of obesity or because of cardiovascular or renal conditions. Because of the frequency of postoperative complications in this group of patients they should be very carefully studied previous to advising operation. Pulmonary complications and thrombophlebitis may follow repair but can usually be avoided. Obese patients should be put on a strict reduction diet and repair should be delayed whenever possible until their weight falls within a normal range. Because of the marked changes in intra-abdominal pressure produced by the repair, it is well during the period of preparation to have them fitted with an abdominal belt to 787
788
RICHARD B. CATTELL
reduce the contents of the hernia as far as possible within the abdominal cavity. In some patients, because of marked disability or abdominal pain, operation must be advised before weight reduction. Likewise, when incarceration is present with threatened or impending strangulation of the contents of the sac, operation must be carried out at a less advantageous time. With large hernias, at times the skin becomes ulcerated because of excessive pressure, and immediate operation should then be advised. Under these circumstances the technic which will be described is particularly applicable since it can be carried out with a minimum of technical difficulties even in very obese patients. The usual technic employed for the repair of incisional hernia includes isolation of the sac and its contents, following which the layers of the abdominal wall are dissected out separately. This is frequently a long and tedious dissection and even when carried out in the best manner possible it may result in obtaining quite weak layers that are not easily sutured owing to their irregularity and weakness. The chief difference in the conventional method of hernia repair and the plan which will be described is that the strong layer of the ring is not disturbed. This ring consists of fragments of the peritoneum, muscle and fascia and, in the upper abdomen, portions of the posterior rectus sheath and transversalis muscle. The layers of the abdominal wall are identified ' subsequently during the repair at some distance from the ring. TECHNIC
. After applying traction to the previous incisional scar, an elliptical incision is made around the scar incorporating the excess skin of the abdominal wall (Fig. 295, a). By firm traction, the contents of the sac will usually fall away. The incision is then continued outward through the layer of fat until the fascia is encountered (Fig. 295, b). These lateral flaps are freed up for a considerable distance laterally beyond the ring of defect, leaving a broad surface of fascia exposed. It is a relatively bloodless procedure. Traction is maintained on the sac and sharp dissection is carried out medially around the entire neck of the sac at its junction with the fascia (Fig. 295, b). When a wide dissection of the flap has been carried out, the skin is incised over the sac, which is entered. The abdominal contents are completely freed from the sac and the dissection carried out well beneath the abdominal wall for the full circumference of the defect. It is frequently advisable to excise large portions of omentum. The skin is excised from the sac, and the fat cut away from its entire surface (Fig. 296, a). With the defect of the abdominal wall outlined, the peritoneum is approximated in a longitudinal direction with a continuous heavy
REPAIR OF INCISIONAL HEHNIA
789
chromic interlocking suture, including all layers of the abdominal wall that are attached to the hernial ring (Fig. 296, b). This can be accomplished even when large defects are present.
Fig. 295.-a, The outline of the hernia is shown. An elliptical incision has been made enclosing the scar and excess skin. b, Lateral flaps have been freed, exposing the fascia. The dissection is then carried medially to expose the edge of the defect in the abdominal wall.
The large redundancy of sac is cut away at a distance of 2 cm. from the previous suture line. This redundant portion of the sac, again con-
790
HICHAHD B. CATTELL
taining portions of peritoneum, muscle and fascia, is approximated with interrupted or continuous chromic sutures immediately overlying the
NECK OF SAC CLOSED
Fig. 296.-a, The sac is opened and the contents freed and reduced. The skin and fat are dissected from thc peritoneal sac. b, Closure of the hernia defect from the inside of the sac. Dotted line shows the line of removal of excess sac.
first suture line (Fig. 297, a). In some patients with large defects these two layers are closed by means of alloy steel wire and the operation is concluded with this simple repair. This is effective in the upper part of
REPAIR OF INCISIONAL HERNIA
791
the abdomen if the previous incision has been made in the linea alba or midline. At times it is sufficient in lower midline incisions as well. It is
a
llil" SUTURE LINE (NECK OF SAC)
Fig. 297.--a, The remaining free edge is sutured. The dotted line shows the position of the fascial incision. b, The medial borders of the fascial layer are approximated. The muscle has been expo~ed.
recommended, however, that a further layer closure be effected, as will be described. An elliptical incision is made at a distance of 2 cm. on each side lateral to the previous suture line in a position as indicated by the dotted line in
792
RICHARD B. CATTELL
Figure 297, a. This exposes the muscle on either side, which may be freed up to any extent desired. The medial borders of the elliptical incision are approximated as the third layer, as indicated in Figure 297, b. The fascial layers are freed up for a considerable distance from the muscle and interrupted sutures are used to approximate the fascia at the upper and lower angles of the incision. This is done to take the tension off the muscle. Muscle sutures are then alternated with fascial sutures until the fourth and fifth layers are completed (Fig. 298). If the fascia approximates with too great tension, the lateral flaps of the incision, including skin and fat, are elevated and counterincisions in the fascia
Fig. 298.-Alternating sutures are taken to approximate muscle and fascia.
are made at some distance laterally. No attempt is made to close the lateral defect. Following the closure of the five layers, the fat and skin are separately sutured. Drainage of the wound is optional and is rarely used except to drain the fatty layer. COMMENT
During the immediate postoperative period, full adhesive strapping to the abdomen is kept in place. Deep breathing exercises are encouraged, as is light coughing. With the abdominal support of a binder, early ambula-
REPAIH 01<' INCISIONAL HERNIA
793
tion is encouraged. We prefer to have the patients remain in bed for two days since all are operated on under pontocaine spinal anesthesia and headaches are avoided if ambulation is begun on the third day. Ace bandages are applied to the legs and leg exercises are carried out at frequent intervals during bed rest. Prophylactic use of dicumarol may be indicated. Patients are discharged from the hospital usually in ten to fourteen days, with a well-fitted canvas abdominal belt. Obese patients are given a low calorie diet and are advised to avoid gaining weight. This plan for the repair of incisional hernia has been used in a large group of patients during the past ten years with very good results. The simplicity of the procedure, which can he carried out rapidly and without an involved dissection, possesses great advantages for the type of patient who has a large incisional hernia. The procedure is equally applicable to hernias located in the upper abdomen, both in the median line and through the vertical incision through the rectus muscle. It has been used more often in lower midline incisions and for low right rectus incisional hernias. The same principle has been employed in hernias of all sizes in all quadrants of the abdomen. In our experience, repair effected by this method is followed by a very low incidence of complications and recurrences.
SUMMARY A technic for the repair of incisional hernia has been presented which is applicable to most incisional hernias irrespective of size. It has been carried out frequently in very obese patients when, because of complications, reduction of weight has been inadvisable. The chief difference between this method of repair and the one generally employed is that the repair is carried out after dealing with the sac and its contents without separate dissection of the layers of the abdominal wall. The hernial ring is approximated, following which the layers are identified and approximated over this preliminary closure.
REFERENCE 1. Cattell, R. B.: An unusual technic for the repair of incisional hernia. S. CLIN . AMERICA :11:11:795-799 (June) 194~.
NORTH