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Open Repair
Flavio Malcher, Leandro Totti Cavazzola,
and Andrew Kingsnorth
Introduction
Signs and Symptoms
An incisional hernia is defined by Pollock and his colleagues
as “a bulge visible and palpable when the patient is standing
and often requiring support or repair” [1].
Sixty percent of patients with incisional hernias do not
experience any symptoms; however, symptoms that predicate medical advice include difficulty in bending, cosmetic
deformity, discomfort from the size of the hernia, persistent
abdominal pain, and episodic subacute intestinal obstruction.
Incarceration persisting to acute intestinal obstruction and
strangulation necessitate emergency surgery.
Spontaneous rupture of incisional hernia is an unusual but
life-threatening complication (Fig. 25.1). This complication
is more likely in infraumbilical hernia. It may be exacerbated
by friction of clothes or corsetry [2]. Hernias after gynecological and obstetric interventions are most at risk [3].
The demonstration of small incisional hernias may be
very difficult. Patients with tiny protrusions of extraperitoneal fat and a small peritoneal sac may complain of a tender
lump, which is not always there, but which causes quite
severe localized pain when it is present. Physical examination of the patient supine and relaxed usually reveals the
cause. Ultrasound examination is a useful diagnostic test and
will often reveal an impalpable defect, particularly in the
obese patient. However, the sonographic examination of the
abdominal wall is dependent upon a skilled interpreter. It is
25
Fig. 25.1 Spontaneous rupture of an incisional hernia
sometimes difficult to differentiate between a hernia and
subcutaneous fat or small bowel in the hernia, as opposed to
being in close proximity to a weakened anterior fascia. In
most situations and particularly for massive complex incisional hernias, CT scan may be much more efficient and
accurate in defining the defect and planning the preoperative
preparation of the patient and the operation chosen. CT scan
is particularly helpful in obesity and in patients with extensive laparotomy scars as it defines the contents of the sac
especially if the abdominal wall hernias are clinically occult.
In addition it distinguished them from other conditions such
as hematoma, abscess, and neoplasia [4].
F. Malcher
Celebration Center for Surgery, Celebration, FL, USA
L.T. Cavazzola
Universidade Federal do Rio Grande do Sul and Hospital de
Clínicas de Porto Alegre, Porto Alegre, Brazil
A. Kingsnorth (
Peninsula College of Medicine and Dentistry (Emeritus),
Plymouth, UK
e-mail: kingsnorthandrewn@gmail.com
© 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_25
*)
Classification of Incisional Hernias
Different grading scores have been proposed to classify
ventral hernias, and classifications are important to allow
better understanding in operative reports, databases, and
trials. The EHS published a comprehensive classification
for both primary and incisional hernias that is easy to use
365
366
F. Malcher et al.
Table 25.1 European Hernia Society classification for incisional
abdominal wall hernias
EHS incisional hernia classification
Midline Subxiphoidal M1
Epigastric M2
Umbilical M3
Infraumbilical M4
Suprapubic M5
Lateral Subcostal L1
Flank L2
Iliac L3
Lumbar L4
Recurrent incisional hernia? Yes O No O
Length: cm Width: cm
Width cm W1 <4 cm O W2 ≥4–10 cm O W3 ≥10 cm O
and understand [5]. It defines localization of the defect, if it
is recurrent or not, and its size, as shown in Table 25.1.
Besides the EHS classification, Rosen et al. proposed a
grading score based on the likelihood of SSI (Surgical Site
Infection) occurrence [6]. It is based on the CDC wound
classification, but proposes a three-grade score only, with
grade 1 cases without any risk factor, grade 2 patients with
comorbidity, and grade 3 contaminated cases.
Conservative Management
The low risk of developing complications of a ventral hernia,
such as strangulation and/or intestinal obstruction, has strengthened the nonoperative treatment in asymptomatic patients.
Assessment of comorbidities and postoperative risks is a key in
this decision process. Bellows et al. observed a small cohort of
patients over a period of 24 months, and there was no effect on
quality of life during the period and only one episode of incarceration during this time period [7]. A prospective cohort of
636 patients (295 with incisional hernia and 341 with umbilical/epigastric hernia) showed that active surveillance is a safe
strategy in anterior abdominal wall hernias [8].
Preoperative Care
The preoperative condition of the patient can strongly impact
the surgical outcomes in ventral repairs. Several risk factors
should be analyzed and the pre-optimization is a key step for
the best result. The modifiable risk factors should be addressed.
35; others are more liberal and have a BMI of 40 as a cutoff.
The International Endohernia Society guidelines for treatment
of ventral hernias point that a BMI over 30 brings increased
risk of bigger defects and recurrence [10]. A strategy to lose
weight should be implemented in the preoperative period for
elective incisional hernias. Self-diets and exercises have very
high failure rates. A medical weight loss specialist should be
consulted, but good results usually happen only in very motivated patients. Bariatric surgery is an option, and a sleeve gastrectomy is the procedure of choice, once the traditional gastric
bypass requires small bowel mobilization, which requires hernia content mobilization. The hernia defect and content management is very critical during the bariatric surgery. If possible,
the content and defect should not be touched. If content mobilization is necessary, the defect left open can lead to small
bowel obstruction. Primary closure of the defect prevents this
complication, but when it is not feasible, an omental patch can
be sutured to the edges of the defect to avoid new bowel incarceration. The definitive hernia repair should be done once the
weight loss is stable, usually after 6 months.
Diabetic Control
Glucose levels can significantly impact wound healing, once
hyperglycemia leads to several alterations in wound healing as
glycosylation of collagen, which is resistant to enzymatic degradation and remodeling, which decreases the strength of the
scar, less granulation tissue, fewer fibroblasts in the dermis, and
altered WBC function (chemotaxis, oxidative burst, phagocytosis). The level of hemoglobin A1c correlates to SSI. HA1c
higher than 8 is correlated to a two times incidence of a SSI in
cardiothoracic surgery [11]. A strict preoperative control of
DM and glucose/HA1c levels should be implemented.
Smoking
Tabaco is still a huge world business with a global market over
US$ 700 billion, and yearly growth around 4%, with over 5
trillion cigarettes produced per year. Smoking results in abnormal wound healing, reduced neutrophil blood count, alteration
in collagen metabolism, and reduced levels of vitamin C [12].
Tobacco use is a significant independent predictor of wound
infection in ventral repair [13]. Abstinence partially reverses
the effects and should be requested for at least 4–6 weeks prior
the surgery. Nicotine blood test should be done in the week
before the surgery to prove the abstinence.
Obesity
Obesity is the number one patient modifiable risk factor predictive of SSI [9]. There is not a magical cutoff BMI. Some groups
do not perform elective ventral repairs in patients over BMI of
Prevention of Infection
MRSA (methicillin-resistant Staphylococcus aureus) decolo-
nization with mupirocin/chlorhexidine has shown decreased
25 Open Repair
367
SSI by S. aureus and can be done universally instead after
screening, one it seems to be more cost- effective this way [14].
A randomized trial comparing the use of antibiotic prophylaxis against no antibiotic in prosthetic incisional hernia
repair has never been carried out. Nevertheless most surgeons consider it the best practice to administer a systemic
dose of antibiotics preoperatively. When combined with a
second dose of antibiotics, a significant reduction in wound
infection occurs even in the context of a clean operation
without contamination [15]. When there are other risk factors such as diabetes, obesity, and previous wound infection,
the need for antibiotic prophylaxis becomes imperative.
Nutrition
The preoperative nutritional status is very important for any
major operation, and the ventral repairs should not be different. Preoperative albumin is the single best predictor of overall procedure risk [16]. Besides the adequate nutrition,
arginine supplementation seems to decrease overall infection
rates and hospital stay in elective surgery and can be given
for 5–7 days before the surgery [17].
Loss of Domain
The definition of loss of domain has been very subjective and
no reliable criterion has been published. In huge and obvious
cases, it is not difficult to make the diagnosis, but in some
smaller cases, it can be not that easy. The volume calculation
of the hernial sac and the abdominal cavity by CT scan can
give a ratio between these two variables that when reaches
over 25% gives the diagnosis of loss of domain as described
by Tanaka et al [18].
Pneumoperitoneum As an Aid in Surgical Treatment of Giant Hernias
Management of giant incisional hernia is often compromised by
obesity, intrahernial adhesions, and contraction in the volume of
the abdominal cavity—the hernial contents have lost their “right
of domain.” The use of pneumoperitoneum before attempting
definitive repair of giant hernias was originally suggested by
Moreno in 1940 [19]. The advantages of the technique are:
The technique has evolved during the last decades, and
recently a simpler technique using a double-lumen intraabdominal catheter inserted through a Veress needle in the
left hypochondrium has been popularized [22]. Daily insufflations of ambient air are utilized over a period or an average
of 9.3 days. A total of between 1000 and 4000 cc of air is
insufflated, depending on patient comfort. The maximum
intra-abdominal pressure reached should be no greater than
15 mm of mercury (measured by sphygmomanometer).
Successful hernia repair is subsequently possible in most
patients.
In practice, the patient is ready for operation at about
2 weeks after induction of the pneumoperitoneum, the end
point being judged by the tension of the abdominal wall, which
should feel as tight as a drum, especially in the flanks. The
patient should be operated on at this stage—if possible most of
the dissection should be performed with the hernial sac unpunctured and distended. When this dissection has been completed,
puncture of the sac allows easy reduction of contents and the
slack parietes will facilitate repair. Air is only slowly absorbed
from the peritoneal cavity, and often after the first 2 or 3 days,
absorption is so reduced as to become inconsequential.
Contraindications to pneumoperitoneum include abdominal wall sepsis, prior cardiorespiratory decompensation, and
suspected strangulation of hernial contents. Complications,
which are very rare, include visceral puncture, hematoma, and
the risk of an embolism into a solid organ if the liver or spleen
is needled prior to insufflation. Mediastinal and retroperitoneal
surgical emphysemas are rare complications. Prophylatic anticoagulation for DVT and respiratory physiotherapy are key to
avoid complications and should be routine.
Botox Injection
Ibarra et al had showed that botulinium toxin injections are
a potential preoperative mean to counteract abdominal wall
tension, reduce hernia size, and facilitate fascial closure
during the definitive procedure [23]. A recent meta-analysis
showed a significant hernia width reduction (almost 6 cm)
and an increase in lateral abdominal wall muscular lengthening (more than 3 cm), showing a potential use especially
in complex ventral hernia management [24]. These excellent results were corroborated by other systematic reviews
demonstrating excellent results with the use of botulinum
toxin in abdominal wall defects [25].
• Stretching of the abdominal wall, creating a larger cavity
into which the hernial contents can be replaced
• Reduction of edema in the mesentery, omentum, and viscera in the hernial sac, creating less mass to be reduced
• Stretching of the hernial sac leading to elongation of
adhesions, making dissection and reduction easier [20]
• Increased tone of the diaphragm, allowing preoperative
respiratory and circulatory adaptation to the elevation of
the diaphragm [21]
Principles of Open Repair
The following principles should be followed:
1. Whenever possible the normal anatomy should be reconstituted, prior to placement of prosthetic mesh. In midline
hernias this means the linea alba must be reconstructed;
in more lateral hernias, there should be layer-by-layer
368
F. Malcher et al.
closure as far as possible. The use of sutures alone for the
repair of incisional hernias is associated with a rate of
recurrence that is at least as high as 43% [26].
2. Only tendinous/aponeurotic/fascial structures should be
brought together. In situ darning over the defect without
adequate mobilization and apposition of the aponeurotic
defect gives a 100% recurrence rate [27].
3. The suture material must retain its strength for long
enough to maintain tissue apposition and allow sound
union of tissues to occur. A slowly absorbable suture
material is recommended.
4. The length of suture material is related to the geometry of
the wound and to its healing. Using bites at not more than
0.5–1.0 cm intervals, the ratio of suture length to wound
length should be 4:1 and not more than 5:1 [28, 29]. Other
fascial defects should be closed similarly.
5. Repair of an incisional hernia inevitably involves returning the viscera to the confines of the abdominal cavity
with a resultant rise in intra-abdominal pressure. It is
important to minimize this.
6. Every care must be taken to prevent abdominal distension
due to adynamic ileus, which will lead to additional stress
on repair suture lines. For this reason, handling of the viscera should be minimized.
7. Postoperative coughing can put an additional unwarranted strain on the suture lines. Hence, pulmonary collapse, pulmonary infection, and pulmonary edema must
be avoided.
8. The repair must be performed aseptically; inoculated bacteria, traumatized tissue, and hematoma should not be
features of these wounds.
Drawing these eight points together, appropriate prepara-
tion for operation includes measures to reduce the risk of
subsequent infection: all skin lesions and erosions should be
resolved before surgery, and pulmonary function should be
optimized. A carefully planned procedure using a repair with
prosthetic reinforcement is recommended in appropriate
patients [30].
Surgical Techniques
are designed to withstand the theoretical maximum intraabdominal pressure of 20 kPa at an average human body
diameter of 32 cm. From this it is calculated that the maximum required tensile strength of any material to maintain
abdominal wall closure is 16 N/cm. All synthetic prosthetic
materials used for incisional hernia repair are designed to this
standard, and the choice is left to the individual surgeon. In a
contaminated or potentially contaminated field, a biological
mesh is favored, and there are many new products to choose
from [32].
The tissue repair or Mayo procedure for repair of
abdominal incisional hernia gives unacceptable results
with recurrence rates of up to 84% with 5.7 years of follow-up [33]. When suture repair for incisional hernia is
compared with mesh repair, the incidence in recurrence at
36 months is reduced from 43% (suture) to 24% (mesh) in
patients with a vertical midline incision of less than 6 cm
in length [26]. However, in this study patients only
received 2 cm overlap of mesh which currently would be
considered inadequate, and the 10-year cumulative rate
for recurrence was 32% for the mesh repair, a figure that
would now be highly unacceptable [34]. Further insight
into the benefit of mesh came from a comparative retrospective study of 421 incisional hernias on 348 patients
undergoing 241 Mayo repairs and 180 mesh repairs over a
25-year period [35]. The total recurrence rate following
Mayo repair was 37% in contrast to 15% after mesh
implantation. In the mesh repair group, the only significant prognostic factor concerning quality of life and
recurrence was the size of the mesh implanted. There
were more wound-related complications in the mesh
repair group, and recurrences occurred at the upper and
lower edges of the mesh where there had been insufficient
overlap.
Position of Patient
If the hernia is located in the midline or lateral aspects of the
anterior abdominal wall, the patient is placed in the supine
position on the operating table.
Tissue Repair vs. Mesh Repair
Due to the poor results of tissue repairs, it is mandatory that
a prosthesis is used in all incisional hernia repairs. Even if
the fascial defect is less than 4 cm, a prosthesis is recommended. The prosthetic materials that are available are
described in Chap. 7.
There are limited clinical data and short-term follow-up for
only a few of the many biological tissue grafts, and additional
clinical studies are required [31]. Prosthetic, synthetic meshes
The Incision
A wide elliptical incision is made to enclose the cutaneous
scar. The incision must generally be extended at either end to
give adequate access to all the margins of the defect. The
direction of this initial incision will depend on the shape of
the original scar through which the hernia has come. Care
should be taken not to excise too much skin: at this stage the
minimum excision of cutaneous scar tissue is carried out
(Fig. 25.2).
25 Open Repair
Fig. 25.2 Elliptical incisions are made on either side of the hernial
cicatrix
369
Removal of Overlying Redundant Tissue
The redundant skin and scar are separated from the underlying hernial sac, which is often lying just under thinly
stretched skin, especially near the fundus of the hernia.
Redundant skin and scar tissue are removed (Fig. 25.3). This
is a significant advantage of the open approach compared
with the laparoscopic method because a better cosmetic
result is achieved.
If the hernia is very large, the skin and underlying peritoneal sac may be virtually fused into one layer near the fundus
of the hernial protrusion. When removing the redundant skin,
care is necessary to avoid damage to the hernia contents which
may be adherent over wide areas inside the sac (Fig. 25.4).
Exposure
The hernia is dissected from the surrounding subcutaneous
fat by raising skin flaps (Fig. 25.5). The surgeon may choose
to use the scalpel blade, scissors, electrocautery pencil, and/
or the ultrasonic dissection device for this dissection. The
coverings of the hernia are stretched scar tissue merging into
the stretched abdominal wall aponeurosis at the circumference of the protrusion and a variable amount of extraperitoneal fatty tissue.
The hernial sac is now dissected out completely following
the contours carefully until the neck of the sac is reached
circumferentially, which in a large hernia will require the
Fig. 25.3 Removal of the redundant scar
Fig. 25.4 Care must be taken not to remove too much skin and not to
damage the hernial sac. The cutaneous cicatrix is often closely adherent
to the sac
370
Fig. 25.5 Skin flaps are raised in order to fully dissect out the sac and
allow placement of the mesh, with or without “components separation.”
A 4–5 cm exposure of the anterior rectus sheath is required on each side
for an onlay (prefascial) repair; less exposure is required for a sublay
(retrorectus) repair
F. Malcher et al.
Managing the Peritoneal Sac
The hernial sac is now opened carefully avoiding damage to
the visceral contents of the sac, either at the fundus or by an
elliptical incision around the hernia neck, where it merges
with the stretched aponeurosis (Fig. 25.7).
It is recommended that the hernial sac is completely
resected in all cases because intra-sac adhesions and sac
compartmentalization can be a potent cause of intestinal
obstruction, if the sac is merely inverted and pushed into
the abdominal cavity. The advent of laparoscopic techniques for incisional hernia repair has revealed that at least
one-third of hernial sacs contain visceral contents which
are adherent to the sac itself. After opening the sac, adhesions of the contents are divided (Fig. 25.8), the viscera
returned to the peritoneal cavity, and then the sac is completely excised to the edge of the rectus fascia/linea alba on
each side (Fig. 25.9). Since the peritoneal layer will not be
sutured separately (it is too weak to retain sutures), complete excision of the sac allows the medial fascial edges of
the rectus sheath/linea alba to be seen clearly for accurate
suture placement when closing the abdomen. A touch of
advice is to reserve the final decision of ressection of the
Fig. 25.6 Circumferential exposure of the neck of the sac is achieved
elevation of large skin flaps (Fig. 25.6). These large areas of
pannus should be removed later by horizontal panniculectomy (see later) to lessen the incidence of seroma formation
collecting in loose folds of the skin.
Fig. 25.7 The sac is opened at a point where it is judged that bowel is
not adherent beneath it, usually at the fundus
25 Open Repair
Fig. 25.8 Adhesions between the bowel and sac are divided, and the
bowel is returned to the peritoneal cavity
371
Contents of the Sac
The sac may contain almost any intraperitoneal viscus, but
usually the omentum, small bowel, and transverse colon are
found.
Unless the hernia is strangulated and the small bowel nonviable, any adhesions are divided and the small bowel is
returned to the abdominal cavity. Strangulated small bowel
or omentum can be resected at this stage. The diagnostic
decision is now made as to what should be done about very
adherent and frequently partially ischemic omentum. If there
is any doubt about omentum, it is best excised. To return the
omentum of doubtful viability to the peritoneal cavity invites
the formation of adhesions.
Particular care must be taken in manipulating and dissecting any colon in the sac. Any densely adherent hernial
sac should be trimmed and left adherent to the bowel and
returned to the peritoneal sac rather than risk perforating
the bowel in a tedious dissection. The greatest care must be
taken to avoid puncturing the colon. If the colon is punctured, a minor injury could generally be closed with sutures.
A substantial injury must be treated by creation of a colostomy; the reanastomosis of the colon and repair of the hernia can be performed at a later operation after full patient
evaluation and colon antibacterial preparation.
Fig. 25.9 Completion of excision of the sac, laying bare the medial
margins (linea alba) of the rectus sheath in preparation for midline fascial closure
hernia sac for after one can assure there will be enough
posterior sheet to close the visceral sac.
Visceroreduction
In extreme situations, when it is not possible to close the
aponeurotic layer, there has been some anecdotal reports of
resection of visceral contents to achieve abdominal wall closure, normally associated with loss of domain and progressive pneumoperitoneum [36].
This normally starts with the omentum, with resection of
the right colon if necessary, extending to the small bowel if
the closure is still not achieved [37].
Panniculectomy
Panniculectomy if required is carried out at this stage
after complete fascial closure. Depending upon local custom, the subcutaneous fat is either left unclosed or is closed
in layers with absorbable sutures. The skin margins are now
approximated. Skin closure must be effected without any
tension. This may be accomplished with sutures and/or skin
staples. It is recommended that interrupted mattress skin
372
F. Malcher et al.
sutures are placed at 1 cm intervals. Skin healing is compromised because the raising of skin flaps has reduced the blood
supply; therefore sutures should not be removed until the
first wound check in the outpatient clinic at 14 days after the
operation.
The Choices of Technique in Open Prosthetic Repair
The choice is between the onlay (prefascial, Chevrel) technique, the sublay (retrorectus, Rives, preperitoneal), and
an intraperitoneal technique. The use of unprotected intraperitoneal mesh in open surgery is not considered appropriate because it leads to adhesion formation between the
mesh and bowel and the risk of fistulation. The retrorectus
sublay repair is considered by many surgeons to be the
method of choice. The mesh sits in a biomechanically
excellent position, and there is less potential space for clinically significant seromas to develop compared to the onlay
repair. However the repair can be technically challenging
especially below the arcuate line, where there is only a preperitoneal plane devoid of posterior rectus sheath, and for
recurrent hernias where the tissue planes maybe severely
disrupted and attenuated. An alternative is the onlay technique, in which the mesh is placed over the abdominal wall
closure in the subcutaneous prefascial space. This technique was refined and popularized by Chevrel and is technically simpler to perform than the sublay repair, but is
often performed poorly without careful attention to closure
of the anterior sheath. The main criticisms of the onlay
technique are the potential for higher rates of wound infections and seroma formation. A hernia surgeon should be
able to perform both techniques well and adopt the most
suitable technique for the individual patient.
For very complex abdominal wall reconstruction, techniques of tissue expansion, vacuum-assisted closure devices,
abdominal components separation, local and distant muscle
flaps, and free tissue transfer can be adopted [38]. However,
for the general surgeon performing incisional hernia repair,
such advanced surgical techniques should only be attempted
in collaboration with a plastic surgeon unless he or she is
familiar with these techniques. In general small hernias
below 10 cm in size are amenable to laparoscopic repair (see
Chap. 16) although they are satisfactorily repaired by the
open technique with the additional benefit of achieving cosmesis of the anterior abdominal wall skin. Hernias between
10 and 15 cm in size are best repaired by open techniques
although advanced laparoscopic surgeons can achieve good
results. Hernias over 15 cm in size usually require a Ramirez
“components separation” of part repair because of significant loss of domain [39].
A Cochrane database of systematic reviews in 2008 concerning open surgical procedures for incisional hernia
included eligible studies if they were randomized controlled
trials comparing different techniques for open incisional
repair. Eight trials were identified of which one was excluded
and 1141 patients had been enrolled into the studies. Three
trials concerned suture vs. mesh repair (onlay or sublay),
which revealed that recurrence and wound complications
were more frequent after sutured repair. Two trials compared
onlay (prefascial) vs. sublay (retrorectus) technique and
found no difference in outcome except for a shorter operative
time for the onlay method indicating its ease of use. Finally
comparison between lightweight and standard mesh showed
a trend for more recurrence in the lightweight group. An
onlay vs. intraperitoneal mesh trial showed no differences in
outcomes except for increased pain in the intraperitoneal
group [40]. The review concluded that open mesh was superior to suture techniques for recurrence and reduction in
wound infection, but there was insufficient evidence as to
which type of mesh or which mesh position (onlay or sublay)
should be used. In addition the study also found insufficient
evidence to advocate the use of components separation technique, and clearly this requires further study. A quasirandomized study allocating patients alternately to either a
sublay or an onlay arm for meshplasty in ventral hernias,
excluding patients with defects greater than 10 cm, found a
more favorable outcome for the onlay technique with complications recurring in 22.5% (sublay) vs. 15% (onlay) with
similar wound complications [41]. Hospital stay was similar
and there were no recurrences.
Onlay (Prefascial, Chevrel) Technique
Chevrel popularized the onlay, prefascial technique more
than 30 years ago [42]. Reporting 257 prosthetic repairs,
Chevrel reported a morbidity of 10.5% including 6.3%
seroma, 2% wound infection, and 4.9% recurrence and
favoring the use of polypropylene mesh. In addition
Chevrel advocated the use of fibrin glue and relaxing incisions in approximately half of his patients. Relaxing incisions were placed in the anterior rectus sheath, which was
a favored technique prior to the introduction of the components separation, which places the relaxing incisions in
the external oblique aponeurosis. Similar results have
been reported in smaller series which advocate a significant overlap of mesh after the midline fascial closure and
extensive suturing of the mesh to the anterior abdominal
wall in order to prevent shifting, curling, or movement of
the mesh allowing recurrence [43–45]. Recurrence rates
in the series ranged from 3 to 16%, which is a satisfactory
outcome for large incisional hernias.
25 Open Repair
373
Panniculectomy is an important adjunct to surgery of the
anterior abdominal wall to allow removement of large flaps
of the skin, which are redundant, once the large underlying
hernial sac has been removed and reduced [46]. Failure to
remove a large pannus or skin flap can result in a troublesome chronic seroma requiring multiple aspirations or surgery if it forms a pseudocyst on the abdominal wall.
Sailes et al. [47] have reported the largest series of onlay
repairs (545 patients, all in addition receiving components
separation), with an 18.3% recurrence rate. In 2008,
Kingsnorth et al. reported the results of onlay repair in a
prospective 24-month audit of 116 patients with major
(>10 cm) incisional hernias. Quality of life was assessed by
a validated questionnaire and telephone follow-up. Fascial
closure required components separation in 18%; postoperative seromas occurred in 9.5%, deep wound infections in
1.7%, and recurrences in 3.4% at 15.4 months [48].
Kingsnorth has accumulated a series of 540 onlay
repairs, with 2–12-year follow-up (mean 5.6 years) which
includes 104 cases receiving components separation. This
latter group of 104 complex patients has been audited prospectively with long-term telephone and clinical follow-up.
All patients had large incisional hernias (median size
384 cm
2
), a transverse gap of 10–30 cm (12.8), age
31–87 years (59), male-to- female ratio of 62:42, ASA
grade 1: 2: 3 ratio of 18: 60: 26, BMI of 17–46.5 (38),
comorbidities in 49%, and pre-op fistula in 9. The complexity of the cases was demonstrated by the following features:
removal of previous mesh required in 42 patients; removal
of previous skin graft in 10; bowel resection, anastomosis,
or enterotomy in 30; panniculectomy in 16; and parastomal
hernia repair in 19. Complete fascial closure was achieved
in 93 patients. Mattress skin sutures were used (to be
removed at 14 days postoperatively) and suction drains
placed under the skin flaps (to be removed at 14 days unless
drainage was continuing at >50 cc/day).
Results included postoperative wound infection in 17
patients, of which 11 were superficial and 6 deep infections.
VAC dressings were applied in 13. Seroma occurred in a
total of 23 cases of which 16 were treated by aspiration on an
outpatient basis and 7 required reoperation. In total there
were 11 reoperations for wound morbidity. Thirteen patients
experienced recurrence: of these three with minor (<5 cm)
asymptomatic recurrences which did not require surgery,
two with minor (<5 cm) symptomatic, and eight with major
(>5 cm) recurrences which were reoperated. Pain was
assessed at 1 year; 85 patients were experiencing no pain, 15
had minor pain not interfering with daily activity, and 4 had
major pain reducing quality of life.
From this extensive experience, the following recommendations can be made to optimize the results of an onlay
repair:
1. Completely resect the sac.
2. Use intact linea alba to close midline with 4:1, suture
length to wound length.
3. Tailor mesh to no more than 5 cm overlap, avoiding mesh
overkill.
4. Use a lightweight, large pore mesh.
5. Remove redundant pannus.
6. Subcutaneous drains for 14 days.
7. Mattress skin sutures for 14 days.
Results of other surgeons are shown in the table below.
Onlay repair results (all reported with <2 years of follow-up)
Recurrence SSI
deVries et al. [49] (n = 13 in RCT)
Godara et al. [41] (n = 100 in RCT)
Venclauskas et al. [50] (n = 57 in
RCT)
Memon et al. [51] (n = 60)
Stoikes et al. [52] (n = 50) sutureless
Gemici et al. [53] (n = 154) 54 m F/U
33%
15% (22% sublay)
10.5% (2% sublay) 49%
6.7% 21%
0%
5.2%
It is worth mentioning the results of Venclauskas who, in
a poorly designed study, achieved the lowest recurrence
reported for a sublay repair and the highest wound infection
for an onlay repair.
The onlay technique is the ideal operation to combine
with components separation in patients with very large incisional hernias with loss of domain [48] (Fig. 25.10).
Incision and Dissection
An elliptical incision removing the previous scar is used.
In order to perform the panniculectomy, triangular wedges
of the skin and subcutaneous fat are removed at the lower
end of the midline scar, which will eventually produce an
inverted T-shaped incision which requires closure with
care and accuracy. Beginning at the fundus of the sac, the
entire sac is carefully dissected down to its neck in order
to expose it completely without opening. At this stage the
skin flap should only be minimally dissected in order to
mobilize the sac and clearing an area of not more than
5 cm beyond the edge of the rectus muscle. The sac is now
opened, and any adhesions between the bowel, peritoneum, and the sac are divided and abdominal contents
returned to the peritoneal cavity. In all cases the sac should
now be completely excised.
In all cases the surgeon should be able to completely
close the midline without tension. Where the width of the
gap between the rectus muscles is relatively small, the anterior rectus sheath on each side may be closed with a strong
running suture of slowly resorbable suture material. Prior
to doing this, the anterior rectus sheath is dissected from