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developed a “pantaloon” hernia after fracture of both rami of
the pubis in a traffic accident. Such “traumatic” hernias are
also recognized after pelvic diastasis in the absence of fracture and often present late and may contain the bladder or
small bowel alone (supravesical).
Hernias related to iatrogenic pelvic fractures, for example,
an osteotomy for congenital dislocation of the hip, are well
described in the literature. Ryan classifies these fracture- related
hernias according to the mechanism of the fracture [137].
1. Due to acute anteroposterior forces acting on the pelvis:
In these instances there is tearing of the rectus abdominis
origin from the pubic crest. The tearing is maximal on the
side opposite to that on which maximum bony displace-
ment had occurred. The damage to the muscle is usually
more severe medially than laterally, leading to the devel-
opment of a broad-necked sac just suprapubically from
the midline extending laterally across the attachment of
the rectus to the pubic crest.
2. Due to lateral or lateral/vertical forces: These fractures
involve the superior pubic ramus with consequent tearing
of the fascial and aponeurotic attachments of the inguino-
femoral region. In these circumstances a direct inguinal
hernia develops through the fascia transversalis
immediately above the bony fracture line. A repair of the
direct hernia corrects the situation.
3. Due to surgical innominate osteotomy: This hernia occurs
in children with congenital dislocated hips. The hernia
following innominate osteotomy is either a direct ingui-
nal hernia, a prevascular femoral (Narath’s) hernia, or a
combination of the two [138].
B.M. Stephenson
Fig. 3.13 Diagram to show how innominate osteotomy predisposes to
inguinal herniation
Following innominate or Salter’s osteotomy, there is a
downward lateral and forward displacement of the lower
fragment of the pelvis produced by a combination of hinging
and rotation at the symphysis pubis [139]. This procedure
leads to an increase in the distance between the edge of the
rectus abdominis muscle and the inguinal and pectineal ligaments. There is a consequent weakening in the posterior wall
of the inguinal canal. The angle between the midline (and,
therefore, the lateral edge of the rectus muscle) and the superior ramus of the pubis is increased by a minimum of 5° when
compared to the opposite side, and there is also an increase in
the distance from the pubic tubercle to the anterior superior
iliac spine. These changes alter the anatomy of the inguinofemoral region predisposing to hernia. It must be stressed that
a consequent hernia is rare, and undoubtedly compensatory
remodeling of the soft tissues occurs as the child develops
after the traumatic procedure (Fig. 3.13). Any earlier musculoskeletal surgery, iatrogenic or not, in the region of the groin
can lead to the later unusual groin herniation (Fig. 3.14).
The use of autologous bone grafts from the iliac crest is
also troublesome. When full-thickness grafts are taken from
the posterior iliac crest, the inferior lumbar triangle is
Fig. 3.14 An external femoral hernia (Hesselbach’s) passing deep into
the thigh below the inguinal ligament lateral to the femoral vessels.
Note the previous incision for corrective hip surgery of uncertain nature
enlarged predisposing to herniation. These “iatrogenic” lumbar hernias cause backache, can be complicated by irreducibility and strangulation, and should be repaired [140]. Bone
grafts from the anterior iliac crest are similarly complicated
by later herniation and require corrective surgery (Fig. 3.15).
Truly blunt traumatic abdominal wall hernias may occur
after both low (falls) or high (motor vehicle accidents)
“energy” impact injuries. Despite the use of early CT scanning, the mechanism of injury is vitally important and a high
index of suspicion is necessary when managing such patients.
High-energy trauma cases may need urgent laparotomy for
concomitant intra-abdominal injuries, whereas in low impact
3 Epidemiology and Etiology of Primary Groin Hernias
73
which 129 patients with a total of 145 inguinal hernias were
included, in 7% the hernia was subjectively attributable to a
single muscular strain [143]. Indeed these authors suggested
guidelines to assist in assessing “causation” in work-related
compensation claims in such patients, which included the
following four recommendations:
1. The patient should have made an official report of the
incident of muscular strain.
2. Severe groin pain must have been experienced at the time
of the strain.
3. The diagnosis of hernia should preferably have been
made within 3 days of the incident (or certainly within
30 days).
4. There should be no previous history of inguinal hernia.
Fig. 3.15 An earlier anterior bone graft site complicated by groin herniation. The sac contained incarcerated omentum
Table 3.4 Severity of abdominal wall injury
Description Grade Incidence (%)
Tissue bruising/contusion I 54
Muscle(s) hematoma II 28
Single-layer disruption III 8
Complete-layer disruption IV 8
IV with herniation V 2
IV with evisceration VI 0
Data from Dennis et al. [141] based on CT scans in 1549 patients with
blunt trauma
injuries, local wound toilet, debridement, and immediate
repair may suffice. In a review of 1549 CT scans from a level
I trauma center, abdominal wall injuries were graded as to
their severity with respect to the documented disruption of
the layers of the abdominal wall [141]. Overall abdominal
wall injuries occurred in 9% of cases (Table 3.4) with those
at risk of later herniation (not necessarily in the groin) estimated to be 16%. The role of subsequent follow-up CT scanning may well define the place of “early vs late” repair of
these injuries. To date the later repairs of such hernias should
probably be undertaken through a preperitoneal approach so
that the anatomy, or lack of it, can be best appreciated.
Exertion and Groin Herniation
There is no firm evidence that strong muscular or strenuous
athletic exertion causes inguinal hernia in the absence of a
fascial and/or muscular abnormality—either acquired connective tissue disease or congenital anomaly of the abdominal wall. Indeed, inguinal hernias (as opposed to sliding
hiatal hernias) are rare in weight lifters [142]. However, in a
study of inguinal hernia and a “single strenuous event,” in
Interestingly, a recent similar study, using structured
postal questionnaires suggested that inguinal herniation may
be attributed to a single event in a similar proportion of
patients [144], but another report questions the appearance
of a hernia (of any type) after such an event [145].
Furthermore “hazard ratios” for reoperation, after a previous
inguinal hernia repair where you might think the area is
already weakened, showed no correlation with different
types of heavy manual work [146].
At the moment the relative importance of genetic, anatomic, and environmental (smoking and heavy manual work)
factors cannot be construed in each case. Manual work or
strain is never, or very rarely, the sole cause of inguinal herniation; it may however reveal an underlying previously asymptomatic one, of which our patient was “clearly” unaware of.
Recent research suggests that persistent straining and heavy
work are relevant (but not causal) to the development of groin
hernia. Recent European research has stressed these environmental factors rather than congenital defects in hernia development [147, 148]. In man and many mammalian quadrupeds,
there is an abstinence of the posterior rectus sheath below the
arcuate line (of Douglas) and an “ineffectual” transversalis
fascia in the groin. Gravitational stresses, while in the erect
posture, amplify this hindrance of weakness, which is an
evolved anatomical defect [149]. The etiology of groin hernia
also has importance in terms of prevention; smoking is a
causal agent but possibly less so in women [150].
In medicolegal terms, the situation remains somewhat
confused—an accident or heavy strain at work is generally
construed as a causal factor in the onset of a hernia, and in
British courts damages are usually awarded. Our current
understanding of the etiology of inguinal hernias casts doubt
on judicial reasoning in many cases. The legal foundation for
compensating a workman who develops a hernia after an
accident at his workplace is the commission of a tort or
breach of contract by his employer. The heads of damages
awarded are for pain or suffering, loss of amenities (usually
sex life), pecuniary loss, medical expenses, and loss of later
74
B.M. Stephenson
earning capacity. The role of a preexisting disability, patent
processus vaginalis or metastatic emphysema, will need offsetting against these “damages.” This is definitely a task for
the judiciary, being largely unrelated to the observations of
natural science [151]. Nevertheless in preparing a medicolegal report, surgeons and other medical experts must carefully
examine all the contemporaneous medical records to support
a claim. If there is insufficient evidence to support a claim,
they have a duty to the court to nullify the plaintiff’s claim
and associated litigation [145, 152]. Finally the risk of a
“work-related” hernia causes many patients to seek surgical
correction of a hernia that is discovered in a preemployment
physical examination (especially in the USA). These hernias
must be repaired regardless of the paucity of symptoms due
to the medicolegal risks to both employer and surgeon.
Conclusions
The incidence of primary groin hernia varies in different
communities. The exact incidence in adult males is very difficult to estimate, but 16% of adult males will undergo operation. The incidence of inguinal hernia is higher in African
people, who tend to have a narrower male pelvis than
Europeans. Of interest is that the incidence of herniation varies considerably even between different African tribes.
Genetic and acquired factors clearly interact to allow a
hernia to develop. However, we are forced to the conclusion that it is the failure of the fascia transversalis to withstand the stresses and strains of an upright posture that is
crucial to the development of an inguinal hernia. A preformed, congenital, peritoneal processus or sac is an
important prerequisite of indirect hernias in children and
of an indirect sac in adults.
Connective tissue defects and imbalances are demonstrated in adult males with inguinal herniation and are
causally related to smoking. Persistently heavy labor is
also associated with herniation.
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Incisional and Parastomal Hernia Prevention
Sofiane El Djouzi and J. Scott Roth
4
Introduction
Incisional hernias (IH) are arguably the most common complication of abdominal surgery with many presentations and
timelines. The incidence of IH repair likely represents only a
fraction of the number of patients who have developed IH, as
many are occult [1] or asymptomatic. Most commonly,
patients will develop a noticeable protuberance within an
abdominal incision with or without associated symptoms.
Patients requiring operative repair of their IH occur costs that
significantly increase overall healthcare costs relative to
those who do not develop hernias [2]. Fortunately, only a
small minority of patients will present with urgent or lifethreatening problems necessitating more urgent hernia repair
with or without bowel resection related to incarcerated or
strangulated viscera. Historically, the presence of an IH was
deemed an indication for repair due to concerns for incarceration and strangulation when nonoperative strategies are
employed [3]. However, IHs present emergently in fewer
than 5% of all cases [4].
Accordingly, strategies to identify patients at greatest risk
for the development of IH have evolved to reduce the incidence of this common condition.
Recent decades have been marked with innovations in
surgery resulting in more precise procedures through smaller
incisions with reduced morbidity [5]. Technologic advancements have enabled surgeons to broaden the net of pathology
that can be safely and effectively managed, resulting in
enhanced overall procedural outcomes and quality of life [2,
6, 7]. More specifically, laparoscopic surgery has dramati-
cally impacted the overall number of open abdominal
S. El Djouzi, MD, MS, FRCS, FACS
Division of GI/Minimally Invasive Surgery, Stritch School of
Medicine, Loyola University Medical Center, Maywood, IL, USA
J.S. Roth, MD, FACS (
Center for Minimally Invasive Surgery, Gastrointestinal Surgery,
University of Kentucky, Lexington, KY, USA
e-mail: s.roth@uky.edu
*)
operations performed in the United States with significant
adoption for many common conditions. However, the use of
open surgical techniques for abdominal surgery remains a
reality today for many procedures due to challenges related
to training, equipment, and patient complexity. Accordingly,
open abdominal operations will likely remain within the
scope of surgery for the foreseeable future. Having said that,
abdominal incisions are associated with not infrequent complications, and the optimal means of abdominal closure has
yet to be elucidated. Despite technical improvement and
adherence to principles [8], the overall incidence of IH following laparotomy is reported to be as high as 20% [9] with
significantly higher rates after postoperative wound infection
and other wound complications [10]. It is also expectedly
higher in patients with genetic predispositions or comorbidities favoring abnormal tissue healing. In a 10-year prospective study by Mudge and Hughes [10], fewer than 50% of
IHs occur in the first year after surgery. Suffice it to say,
patient follow-up in excess of 1 year is needed to adequately
assess the true incidence of hernia. Gallup et al. [11] concluded that a 10-year follow-up of such patients is probably
needed to determine the actual incidence of IH. The associated costs attributed to the long-term incidence of IH formation result in significant economic [12] and health
management burdens [13–15] which are likely further compounded considering the not insignificant rate of recurrence
following IH repair (despite the widespread use of mesh as
reinforcement) [16]. Significant medical comorbidities,
advanced preoperative wound class, and postoperative complications further increase costs of ventral hernia repair [17].
Patient risk factors and the mechanism behind IH are well
studied [16, 18, 19]. Although not inclusive, obesity [20],
connective tissue disorders, chronic obstructive pulmonary
disease, tobacco use, malnourishment, corticosteroid dependency, and prostatism are among the most notable [21]. In
light of the risks associated with IH repair [22] and the
impact upon quality of life, the prevention of IH should be
the primary goal at every instance an abdominal incision is
created.
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_4
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80
S. El Djouzi and J.S. Roth
More than 2 million open abdominal operations are performed annually in the United States with approximately
100,000 patients undergoing IH repair annually [23]. The
technique of abdominal wall closure is one of the most
important factors in the prevention of IHs [24]. It is arguably
the only risk factor that is entirely within the control of the
surgeon. Aponeurotic tissue needs a considerably longer
time to heal than, for example, skin and mucosa. A normally
healed wound will obtain 50% of its original strength after
approximately 6 weeks [25], and the aponeurosis may never
completely regain its original strength (only 60–90% after
1 year) [26]. During the period of wound healing, the technique for closure and suture material will greatly impact
overall the strength of incision. Numerous studies have been
conducted in an attempt to identify the optimal fascial closure, evaluating suture materials [27] and suturing technique
[28]. The short stitch technique for wound closure utilizing a
2-0 slowly resorbing suture has emerged as a technique with
a lower incidence of IH rates compared to a traditional running closure utilizing a looped suture in prospective studies
[29]. While dramatic and significant reductions in IH rates
(38%) have been demonstrated by altering the technique for
suture placement, rates of IH remain in excess of 10% in this
study. As a result, the development of additional strategies to
further reduce the incidence of IH formation continues to
In an effort to decrease occurrence of IHs, investigators
have pioneered techniques for mesh reinforcement of abdominal wall closure following elective laparotomy for patients
deemed to be at increased risk for hernia formation. These
“high-risk” patients often demonstrate comorbidities including obesity, smoking, immunosuppression, steroid use, and
abdominal aortic aneurysm. Numerous mesh materials and
techniques for mesh placement have been evaluated. By
choosing to use mesh as an adjunct to the abdominal wall
closure, surgeons must consider not only the incidence of IH
formation but also cost-effectiveness, risk for mesh complications, impact upon future operations, and quality of life.
Mesh Prophylaxis Use at the Time of Midline Laparotomy Closure
The earliest descriptions of the use of prophylactic mesh as
an adjunct to laparotomy closure were in the 1990s at the
time of open weight loss surgery [30]. The authors studied
the IH outcome on 288 morbidly obese patients randomly
assigned to polyglactin mesh (21.5 × 26.5 cm) reinforcement (144 patients) compared to sutured midline laparotomy wound closure (144 patients). They excluded patients
with any history of prior midline incisions from their series.
Interestingly, the intraperitoneal mesh was not secured, but
care was taken to spread it as far as possible into the flanks.
With a follow-up averaging 30 months, 83% of the patients
were evaluated through physical examinations, while the
remaining were assessed through phone and mail communication. Eighty-seven percent of the hernias were observed
during the first 18 postoperative months, and the incidence
of IH was similar between mesh (23%) and non-mesh
group (28%). The authors concluded that intraperitoneal
absorbable prosthetic mesh was not successful in reducing
IH rates in the morbidly obese population, although the
study demonstrated risk factors for hernia formation
including advanced age, male gender, and high
BMI. Although not successful in reducing IH rates, from
this study was born the concept of mesh prophylaxis for IH
prevention.
The use of a permanent synthetic mesh offers some potential advantages over a rapidly absorbed mesh in the prevention of hernia by buttressing the abdominal wall in the event
of early fascial dehiscence. In the event of small fascial separations, the permanent prosthetic remains in position, stabilizes the fascia, and prevents herniation. As many IHs begin
as an occult fascial dehiscence, reinforcement of the incision
with a permanent mesh serves to protect the incision from
the postoperative problems (suture failure, knot failure, fascial tears, etc.) that may result in fascial separation. While
the use of reinforcing synthetic mesh has appeal, safety concerns related to potential for mesh complications require
address. Furthermore, an appreciation of the costeffectiveness of mesh prophylaxis is required in order to
appreciate not only the savings associated with a reduction in
IH rates but also to appreciate any increased costs associated
with the management of complications related to the use of
mesh as prophylaxis. In light of the potential for morbidity
associated with implanting a permanent synthetic mesh prophylactically, most studies to date have evaluated the use of
prophylactic mesh in patients at greatest risk for incisional
hernia formation.
Synthetic polypropylene mesh has been studied in the
prophylaxis of IH repair following gastric bypass [31, 32]. In
a prospective randomized trial, 36 gastric bypass patients
undergoing abdominal closure with a retrorectus polypropylene mesh (8 cm width with extension 2 cm beyond incision
cranially and caudally) were compared to 38 patients who
underwent mass closure of the abdominal wall with 2-0
polypropylene suture. With follow-up ranging from 6 to
38 months, there was no difference in adverse events or
major complications related to either the mesh placement or
the gastric bypass between groups. The incidence of seromas
and minor wound complications was similar in both groups.
The incidence of hernia formation was 21% in the suture
group and 3% in the mesh group. Although this study was
not blinded, these results reinforce the results of a prior nonrandomized study by the same author [32] in which hernia
rates were dramatically reduced with mesh prophylaxis. In
4 Incisional and Parastomal Hernia Prevention
81
these studies, the polypropylene mesh was placed in an onlay
location (reportedly to minimize the risk of bowel fistula of
intraperitoneal mesh location) and used on morbidly obese
patients who were considered at the greatest risk of postoperative hernia or evisceration (BMI of 45 kg/m2 or higher,
history of abdominal hernias, and liver function tests suggesting profound liver damage or cirrhosis).
Abo-Ryia et al. [33] replicated similar outcomes in a randomized controlled trial of morbidly obese patients undergoing prophylactic preperitoneal mesh placement following
weight loss surgery. The polypropylene mesh was approximately 4–5 cm longer than the wound length and 10–12 cm
wider. Postoperative wound-related complications (seroma,
infection, and partial dehiscence) were similar between
groups and were all managed conservatively. Over a mean
follow-up of 4 years, the incidence of IH in the prophylactic
mesh group (3.1%) compared favorably to the non-mesh
group (28.1%) p < 0.01. Among advantages of mesh placement in the retrorectus space, the authors felt it would not
hinder any aesthetic abdominal surgery planned following
maximum weight reduction.
In contrast, others have reported favorable outcomes with
placement of a prophylactic mesh in the intraperitoneal position [34]. In this study, 40 high-risk patients at risk for the
development of IH were randomized into matched groups of
20 patients, with patients undergoing closure with either
polypropylene suture or an intraperitoneal polypropylene
with 2 cm overlap secured with only 4 corner sutures. The
incidence of seroma, surgical site infection, and partial
wound disruption was similarly low in both groups. With a
follow-up averaging 3 years, only one patient (5%) in the
mesh group and three patients (15%) in the non-mesh group
developed IHs. However, chronic wound pain was only seen
in the mesh group (three patients) but was not statistically
significant. While not significant, the potential for meshrelated complications associated with prophylactic mesh
placement requires further consideration. This study sheds
some insight into the potential for chronic pain associated
with prophylactic mesh. Larger studies with attention to
quality of life metrics, including pain, are needed to appreciate all potential impacts, both intended and unintended of the
use of prophylactic mesh to prevent IH.
A larger prospective randomized study of 100 high-risk
patients compared standard fascial closure with and without
the onlay placement of a heavyweight (82 g/m
2
) knitted polypropylene mesh with 3 cm overlap [34, 35]. With 3-year
follow-up in 88 of the patients (44 in each group), the mesh
group experienced no IHs, whereas 5 hernias (11.3%)
occurred in the non-mesh group. Postoperative pain was
noticed in the mesh group and persisted beyond 3 months in
2 patients. A decade later, Caro-Tarrago et al. [36] studied
onlay mesh use with 3 cm overlap to reinforce abdominal
wall closures at the time of elective supra- and infraumbilical
laparotomies. This study utilized a macroporous lightweight
2
(40 g/m
) polypropylene mesh and included high- and lowrisk patients and patients with all degrees of wound contamination; exclusion criteria included patients with ASA score
greater than 3, patients with prior herniorrhaphy or ostomy,
and patients on steroid therapy. Eighty patients in each arm
underwent oncologic or gastrointestinal operations with
1-year follow-up. A significantly higher rate of seroma was
encountered in the mesh group (28.8%) compared to the
standard abdominal wall closure (11.3%). Although most
(73.8%) of the mesh group cases were contaminated, there
was no impact on the rate of either superficial (6.3%) or deep
(3.8%) wound infection rates. No mesh explants were
reported. This study suggests safety in using prosthetic mesh
in contaminated wounds as have other series [37]. The lightweight mesh dramatically decreased the rate of IH (1.5%) in
comparison to the non-mesh group (35.9%), and no patient
experienced chronic pain. The differences in lightweight and
heavyweight polypropylene mesh are often debated.
Lightweight mesh was popularized as a material with reduced
mass of polypropylene often with greater porosity allowing
for rapid integration into the abdominal wall. In a meta-analysis comparing lightweight mesh to standard polypropylene
in hernia repair, the former has been associated with less
chronic pain [38, 39]. Others have reported the use of lightweight polypropylene mesh in contaminated hernia repair
with incidences of mesh removal less than 5%. However, the
incidence of hernia recurrence is higher with lightweight
polypropylene relative to other non-lightweight materials. It
is not clear as of now whether the use of lightweight mesh for
IH prophylaxis will result in improved outcomes relative to
heavyweight polypropylene. Although speculative, there
may be patient populations that are best served with different
mesh types when performing IH prophylaxis.
The ideal technique for mesh fixation in IH requires
investigation. Mesh placement strategies include absorbable
and permanent suture, tacking devices (i.e., tackers, staplers), glues, self-adhering mesh, or fixation-free placement.
Timmermans et al. [39] published short-term outcomes of an
ongoing randomized controlled trial (RCT) comparing standard suture with glued onlay mesh and glued sublay mesh
augmentation. The onlay mesh group experienced a greater
incidence of wound seroma (18.1%) than the sublay group
(7%) with an odds ratio of 2.9, while the non-mesh group
showed the lowest rate of wound seroma (4.7%). Increased
seroma rates with the onlay approach may be explained by
the dead space following the creation of the suprafascial
flaps and the inherent characteristics of the mesh use.
However, a large proportion of postoperative seromas are
clinically innocuous and resolve without intervention.
Nevertheless, an appreciation of the implications of each
mesh position is important in determining the ideal strategy
for mesh placement in prophylaxis.
82
S. El Djouzi and J.S. Roth
Abdominal Aortic Aneurysm Incisional Hernia Prophylaxis
Aneurysmal disease of the aorta has been associated with a
fivefold [40] increased risk of IH development compared
with those patients undergoing surgery for aortic occlusive
disease with rates as high as 38% [41]. Bevis et al. [42]
reported an excellent outcome of their RCT with the use of
preperitoneal polypropylene mesh as a reinforcement of the
laparotomy closure at the time of open elective abdominal
aortic aneurysm (AAA) repair. In this study, there were no
exclusion criteria, and patients were not stratified. Among 85
randomized patients, 40 patients had a 15 × 15 cm polypropylene mesh placed preperitoneally before fascial closure,
and 45 patients underwent standard fascial closure. With a
follow-up ranging from 35 to 1510 days, the incidence of IH
was significantly lower in the mesh group (13.5%) than in
the non-mesh group (37.2%). Two infectious events in each
group were recorded without any mesh infection. Two cases
of seroma were recorded in the mesh group that did not have
any significant consequences. A 2016 study of 120 AAA
patients prospectively undergoing IH prophylaxis with a
large-pore lightweight polypropylene mesh in the preperitoneal space performed at 8 centers demonstrated a reduction
of IH rates from 28% to 0% with no mesh infections or
increase in wound complications, although operative time
was increased by 16 min [29].
In 2013, a task force group was created with the goal to
investigate and elaborate guidelines for “the prevention of
IH” [43]. The group reviewed the previously detailed six randomized controlled trials covering the 2003–2014 period, all
of which studied different variants of polypropylene mesh in
different anatomical locations. Despite the favorable and
consistent data for prophylactic mesh augmentation, the
Guidelines Development Group decided that larger trials are
needed to make a strong recommendation to perform prophylactic mesh augmentation for all patients within certain
risk groups.
At this time, there appears to be a benefit to IH prophylaxis with synthetic mesh in the studied patient populations.
However, many unanswered questions remain regarding
mesh type, mesh location, and mesh fixation. While all techniques appear safe and beneficial relative to sutured closure
alone, it is unclear which strategy is most efficacious with
the lowest incidence of adverse events.
Biologic Mesh IH Prophylaxis
Biologic meshes represent a heterogeneous group of materials derived from different biologic sources and have in common the valuable inherent property of being resistant to
infection [44]. Despite their expense, their efficacy in
complex and contaminated surgical environments is well
established. Synthetic meshes have demonstrated efficacy in
hernia repair, but their use is more frequently associated with
wound infection compared to suture repair [45]. This fact has
prompted some authors to investigate the use of the alternative biologic mesh as a reinforcement material to the laparotomy closure at the time of contaminated surgical
operations (i.e., open bariatric surgery, etc.) or to prevent
future prosthetic graft infection (i.e., open AAA repair, etc.).
Sarr et al. [46] conducted a RCT targeting the outcome of
porcine small intestinal submucosa mesh in the reinforcement of the midline incision after primary and revision
Roux-en-Y gastric bypass surgery. A total of 380 morbidly
2
obese patients with BMI averaging 48 kg/m
(range: 35–79)
were selected excluding patients with pre-existing IH, known
connective tissue disorder (i.e., Ehlers-Danlos syndrome),
diastasis recti, umbilical hernia >2.5 cm in diameter, or
active infection at the time of operation. The technique
involved placement of the mesh with 4 cm lateral and 2 cm
cranial/caudal overlap in a preperitoneal location with
peripheral transfascial stitches and no associated drains.
Two-year prospective follow-up was achieved in 75% of the
139 patients randomized to mesh reinforcement and in 72%
of the 141 patients with standard fascial closure. There was
no difference in IH rates between groups (17.3% mesh vs.
19.5% suture) in this study.
A study of gastric bypass patients undergoing hernia prophylaxis with a human acellular dermal matrix demonstrated
a benefit compared to sutured closure alone [47]. This study
utilized an intraperitoneal mesh placement using a 16 × 6 cm
mesh. Significantly, more seromas (13.6%) were seen in
association with mesh use compared to 1.6% in the nonmesh group. The incidence of IH at mean follow-up of
17 months was 2% in the mesh group compared with 18% in
concomitant nonrandomized controls, suggesting a benefit to
IH prophylaxis with a human acellular dermal matrix.
A study of 40 patients using bovine pericardium mesh
[48] as a reinforcement of the midline laparotomy closure at
the time of AAA repair utilized an onlay mesh with 4 cm
overlap secured with a running nonabsorbable suture compared to sutured closure. Patients underwent annual physical
examination and CT scan. With a 3-year follow-up of 95%,
there were two seromas in the mesh group and one in the
sutured closure. No other wound complications were
recorded in either of the groups. The non-mesh group IH
incidence was 31.6%, whereas no patients in the mesh group
developed hernias.
The mixed results seen with IH prophylaxis utilizing biologic meshes are unable to clearly demonstrate a benefit. The
overall small study sizes and heterogeneity in patient population and technique limit applicability. Appealing to the use of
biologic mesh in IH prophylaxis is the inherent properties of
biologic mesh resulting in infection resistance. The infection