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318 M.S. Kavic et al.
Inguinal
ligament
Pectineus
muscle
Fig. 20.5 Obturator anatomy
Inguinal
hernia
Femoral
hernia
Obturator
hernia
Fig. 20.6 Obturator nerve, artery, and vein
Obturator hernia sacs that follow the anterior division of the
obturator nerve pass between the pectineus and above the
obturator externus muscle. Hernia sacs that follow the posterior division of the obturator nerve pass through the obturator
externus muscle.
2. Howship-Romberg sign
3. History of previous attacks
4. Palpable mass (rare)
Although the fi rst two are the most common signs, the nature
of intestinal obstruction is usually unclear and the HowshipRomberg sign only recalled after exploration has revealed
the presence of obturator hernia.
A palpable mass is occasionally noted on rectal or pelvic
examination. However, since obturator hernia is rarely considered in a differential diagnosis of vague abdominal pain, the
presence of a mass in the obturator region is rarely sought.
John Howship fi rst noted the pain characteristic of obturator hernia in 1840. He described this pain as extending down
the inner surface of the involved thigh, exacerbated by thigh
extension, adduction or medial rotation [
17 ] (Fig. 20.7 ).
Howship’s sign was independently described by Moritz
Romberg in 1848 [
18 ] . Although the Howship-Romberg sign
is pathognomonic of obturator hernia, by no means is it
invariably present. About 50% of patients will complain of
this pain down the inner aspect of their thigh caused by compression of the cutaneous branch of the obturator nerve in the
narrow con fi nes of the obturator canal [
14, 19 ] .
Some have suggested that an obturator hernia develops
over several stages. It fi rst begins as a prehernia with a plug
of preperitoneal connective tissue or “pilot tag” entering the
obturator canal [ 14 ] (Fig. 20.8 ). This concept was supported
by a post mortem study of female cadavers. In this report, a
“pilot tag” was found in 64% of female cadavers that were
examined [ 20 ] . The second stage of obturator hernia formation continues with dimpling of the peritoneum over the
obturator canal and progresses to invagination of a peritoneal
sac (Fig. 20.9 ). Finally in the evolution of an obturator her-
nia, bowel, uterus, tube or ovary may enter the peritoneal sac
and pass along the obturator canal.
Chronic pelvic pain can result from incarceration of tube
or ovary in the obturator hernia. Symptomatic intestinal
obstruction can result from incarceration of small or large
bowel in the obturator canal. Delay of diagnosis, however, is
common as an obturator hernia is usually not visible or even
palpable because of its deep location between the pectineus
and adductor longus muscles.
More recently, computerized tomography has developed
into a reliable diagnostic tool for evaluation of patients with
possible obturator hernia. In two small series, CT scans
detected the presence of an obturator hernia in 87 and 100%
of the cases studied [ 12, 13 ] .
Clinical Presentation
Historically, obturator hernia has been associated with four
signs or symptoms [ 14 ] .
1. Intestinal obstruction ( elderly females, frequently
intermittent)
Treatment
Despite advances in imaging technology, the mainstay of
diagnoses and treatment remains abdominal exploration.
Exploration may be via open laparotomy or with laparoscopic visualization. Regardless of the method used to obtain
31920 Hernias of the Pelvic Wall
Articular
branch (hip)
Posterior
branch
Articular
branch (knee)
Fig. 20.7 Howship-Romberg sign in obturator hernia
Anterior branch
Cutaneous branches
Fig. 20.9 Reduction of an obturator canal hernia
access, the entire pelvis must be examined and evaluated. If
bilateral obturator defects are found, both hernias should be
repaired.
After an obturator hernia has been identi fi ed, contents of
the sac are reduced and a preperitoneal dissection is done to
expose the internal obturator opening and obturator canal. At
this point, the internal opening of the obturator canal can be
closed with permanent mono fi lament suture securing periosteum of the symphysis pubis to fascia of the internal obturator muscle. It is necessary to take care not to injure the
obturator nerve or obturator vessels. An alternative method
to repair obturator hernia is to use permanent synthetic mesh
to secure the breach in the obturator membrane.
Polypropylene, polyester, or expanded polytetra fl uoroethylene
mesh can be used. Mesh must cover the entire defect with a
2.5–3.0 cm overlap circumferentially and secured with adequate fi xation. In addition to the obturator opening, it is usual
to cover the entire myopectineal ori fi ce—femoral and inguinal ori fi ces—with mesh (Fig. 20.10 ).
After the mesh has been secured, the operative area is reperitonealized . Typically, the peritoneal incision is closed
with an intracorporeal running suture of 2-0 absorbable
suture; polydioxanone or polyglactin 910 are suitable choices
(Fig. 20.11 ).
Fig. 20.8 Obturator canal pilot tag
Perineal Hernia
Perineal hernias are very rare hernias that insinuate themselves through muscle and fascia of the pelvic fl oor (pelvic
diaphragm) into the perineum (Fig. 20.12 ). Perineal hernias
have also been called ischiorectal hernias, subpubic hernias,
pudendal hernias, posterior labial hernias, hernias of the
pouch of Douglas and vaginal hernias. Perineal hernias are
320 M.S. Kavic et al.
Fig. 20.10 Obturator hernia mesh repair with tacks
Fig. 20.11 Closure of the peritoneum in obturator hernia repair
commonly found in women and are true hernias with a distinct peritoneal sac.
Factors thought to contribute to perineal hernia include
the broad female pelvis, childbirth, injuries incident to childbirth, obesity, exenteration procedures for pelvic cancer,
abdominal perineal resection, and, in men, perineal prostatectomy. Perineal hernias may present anterior or posterior to
the super fi cial perineal muscle, though the levator ani, or
between the levator ani and coccygeus muscle.
perineal muscles [ 20 ] . A posterior perineal hernia may
emerge between fi bers of the levator ani or between the levator ani and coccygeus muscles, [
21, 22 ]
Presentation
Perineal hernias are bounded by compliant muscle and soft
tissue and, as such, rarely cause intestinal obstruction. They
can, however, cause chronic pelvic pain. Typically, perineal
hernia present as a palpable, soft bulge in the perineum that
is easily reducible or reduces itself when the patient is recumbent. If an overt perineal bulge is not evident, herniography
with intrabdominal instillation of radio opaque dye may be
used to further re fi ne a diagnosis of perineal hernia
(Figs. 20.13 , 20.14 , 20.15 and 20.16 ) .
Treatment
The only de fi nitive treatment for perineal hernia is surgical
repair. Access to a perineal hernia can be obtained via a
perineal incision, or transabdominally using open laparotomy or laparoscopic techniques. Traditionally, these hernias
have been repaired by closure of the perineal defect with non
absorbable suture and the patient’s own tissues. This procedure, while grounded in the principles of classic open surgery, has the disadvantage of using attenuated muscle and
fascia to secure the repair.
Another approach that is gaining favor for the evaluation
of abdominal and pelvic wall hernias has been that of laparoscopy [ 11 ] . A transabdominal laparoscopic examination offers
the bene fi t of minimal access with maximum visualization of
potential hernia sites in the abdominal and pelvic cavities.
Once a perineal hernia has been visualized, its contents are
reduced and a preperitoneal dissection carried out to de fi ne
the borders of the hernia defect. Permanent synthetic mesh is
used to cover and overlap the hernia defect with a 3 cm margin. Laparoscopic suture, staples or tacks are used to fi x the
mesh and the operative area is reperitonealized closing the
peritoneal incision with intracorporeal absorbable suture.
Supravesical Hernia
Anatomy
A pudendal hernia is an anterior perineal hernia that occurs
only in females. This hernia is also known as a labial hernia
and may protrude into the labium majus as an overt mass. A
pudendal hernia exits the pelvis through a triangle bounded
by the bulbocavernosus, ischiocavernosus and transversus
Supravesical hernias are herniation of abdominal content
through a supravesical fossa of the anterior abdominal wall.
They are classi fi ed as either external or internal supravesical
hernias [ 22 ] . External supravesical hernias pass inferiorly
through the supravesical fossa to present medially as direct
inguinal hernias or intraparietal hernias of the anterior inferior abdominal wall. Internal supravesical hernias pass downward to enter the retropubic space of Retzius (Fig.
20.17 ).
Fig. 20.12 Perineal hernia
32120 Hernias of the Pelvic Wall
Anterior perineal
hernia
Bulbocavernosus muscle
Superficial transverse
perineal muscle
Levator ani muscle
Posterior perineal
hernia
Gluteus maximus
muscle
Fig. 20.13 Perineal herniography (Note: the arrow is an X-ray mark
and is irrelevant to the present discussion)
The diagnosis of supravesical hernias that exit through
the posterior inguinal wall or femoral canal may be obvious.
However, an internal supravesical hernia that passes into the
retropubic space of Retzius is usually more dif fi cult to diagnose. Although a small bowel series, ultrasound or computed
tomography may aid in the workup, diagnosis is usually
made at abdominal exploration.
Management of supravesical hernia is that of operative
repair. Hernias that present as external supravesical hernias
(i.e. as direct hernias) may be managed with traditional
Fig. 20.14 Perineal herniography
Bassini or Shouldice herniorrhaphy techniques or Lichtenstein
anterior hernioplasty with mesh. Hernia in the retropubic
space of Retzius—internal supravesical hernia—may be better served with a transabdominal laparoscopic approach that
permits a complete visualization of abdomen and pelvis. As
with other hernias of the abdomen and pelvic wall, a preperitoneal dissection is performed after reduction of hernia content. Hernioplasty with appropriate synthetic mesh and
adequate overlap of hernia margins is followed by reperitonealization of the operative site.
322 M.S. Kavic et al.
Fig. 20.15 Perineal herniography. If an overt perineal bulge is not evident, herniography with intraabdominal instillation of radiopaque dye
may be used to further re fi ne a diagnosis of perineal hernia
Fig. 20.16 Perineal herniography: X-ray fl uoroscopy over 1 h
Hernia within retropubic
space of Retzius
Symphysis pubis
Fig. 20.17 Supravesical retropubic hernia
Supravesical hernia
Urinary bladder
Conclusion
In years past, diagnosis of hernia was only seriously entertained when a mass was seen or a bulge was palpable at a
hernia’s point of presentation. This mindset did not include
the possibility of non-visualized, non-palpable symptomatic
hernias that were evident only at their site of origin [
23– 26 ] .
All the same, non palpable, clinically signi fi cant occult hernias do exist and in one series constituted 8% of those hernia
cases repaired [ 23 ] .
Occult symptomatic abdominal and pelvic wall hernias can
be visualized at their site of origin with advanced imaging and
during laparoscopic exploration. The use of laparoscopic visualization allows for the diagnosis and repair of common and
rare abdominal and pelvic wall hernias at their site of origin
rather that at their point of presentation. A principle of hernia
repair that was fi rst clearly articulated by Henri Fruchaud in
his 1956 insightful discussion of groin anatomy and description of an abdominal myopectineal ori fi ce [ 26 ] .
References
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3. Carter JE. Surgical treatment for chronic pelvic pain. JSLS.
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4. Rapkin AJ, Mayer EA. Gastroenterologic causes of chronic pelvic
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ferential diagnosis, prognosis and treatment. 3rd ed. St Louis: CV
Mosby; 1948.
7. Miklos JR, O’Reilly MJ, Saye WB. Sciatic hernia: a cause of chronic
pelvic pain in women. Obstet Gynecol. 1998;91(6):998–1001.
32320 Hernias of the Pelvic Wall
8. Cali RL, Pitsch RM, Blatchford GJ, et al. Rare pelvic fl oor hernias:
report of a case and review of the literature. Dis Colon Rectum.
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9. Gaffney LB, Schand J. Sciatic hernia: a case of congenital occurrence. Am J Surg. 1958;95:974.
10. Losanoff J, Kjossen K. Sciatic hernia. Acta Chir Belg.
1995;95(6):269–70.
11. Kavic MS. Laparoscopic hernia repair. Amsterdam: Harwood
Academic Publishers; 1997. p. 33–40.
12. Haraguchi M, Matsuo S, Kanetaka K, Tokai H, Azyma T, Yamaguchi
S, Kanematsu T. Obturator Hernia in an Aging Society. Ann Acad
Med Singapore. 2007;36(6):413–5.
13. Nakayama T, Kobayashi S, Shiraishi K, Nishiumi T, Mori S, Isobe
K, Furuta Y. Diagnosis and treatment of obturator hernia. Keio J
Med. 2002;51(3):129–32.
14. Gray SW, Skandalakis JE. Strangulated obturator hernia. In: Nyhus
LM, Condon RE, editors. Hernia. 2nd ed. Philadelphia: JB
Lippincott; 1978. p. 427–42.
15. Bjork KJ, Mucha P, Cahill DR. Obturator hernia. Surg Gynecol
Obstet. 1988;167(3):217–22.
16. Ritz TA, Deshmukh N. Obturator hernia. South Med J.
1990;83:709–12.
17. Howship J. Practical remarks on the discrimination and appearances of surgical disease. London: John Churchill; 1840.
18. Romberg MH. Die Operation des singeklemmten Bruches des
eirunden Loches. Operatio hernia foraminis ovales incarceratae. In:
Dieffenbach JF, editor. Die operative chirurgie, vol. 2. Leipzig: F.A.
Brockhaus; 1848.
19. Chung CC, Mok CO, Kwong KH, Ng EK, Lau WY, Li AK.
Obturator hernia revisited: a review of 12 cases in 7 years. J R Coll
Surg Edinb. 1997;42:82–4.
20. Singer R, Leary PM, Hofmeyer NG. Obturator hernia. S Afr Med J.
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21. Koontz AR. Perineal hernia. In: Nyhus LM, Condon RE, editors.
Hernia. 2nd ed. Philadelphia: J.B. Lippincott; 1978. p. 453–62.
22. Gray SW, Skandalakis JE, McClusky DA. Atlas of surgical anatomy. Baltimore: Williams & Wilkens; 1985. p. 326–7.
23. Herrington JK. Occult inguinal hernia in the female. Ann Surg.
1995;181:481–3.
24. Fodor PB, Webb WA. Indirect inguinal hernia in the female with no
palpable sac. South Med J. 1974;64:15–6.
25. Bascom JU. Pelvic pain. Perspect Colon Rectal Surg.
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26. Fruchaud H. The Surgical Anatomy of Hernias of the Groin.
(Translated and edited by Robert Bendavid, 2006). France: Gaston
Doin & Cie; 1956. Printed in Canada by University of Toronto
Press, First printing 2006.
Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
Andrew N. Kingsnorth
2 1
Historical Note
Incisional hernia is iatrogenic and its incidence has
increased with each increment of abdominal surgical intervention. An incisional hernia is the most perfect example of
a “surgeon-dependent variable.” The introduction of continuous ambulatory peritoneal dialysis was followed by its
own unique harvest of incisional hernias [
surgery also added a new entity: “port site” hernia (Chap. 18)
[ 3 ] . Although it was hoped that the latter would become
infrequent with the advent of smaller ports, the overall
incidence of abdominal wall herniation in the CLASICC
trial of laparoscopic vs. open surgery for colorectal cancer
revealed that there was no reduction in the incidence of
abdominal wall hernias (9.2% in the laparoscopic group vs.
8.6% in the open group) comparing open resection vs. laparoscopic surgery [ 4 ] .
The development of abdominal surgery in the nineteenth
century—the excision of an ovarian cyst by McDowell in
1809 [ 5 ] , partial gastrectomy by Billroth in 1881 [ 6 ] , and
cholecystectomy by Langenbuch in 1882 [ 7 ] —has been fol-
lowed by operations to manage the incisional hernias which
followed as complications. Gerdy repaired an incisional hernia in 1836 and Maydl another in 1886 [
and Gibson in 1920 [
based on extensive anatomic dissection of the scar and adjacent tissues. Prosthetic materials were introduced early on:
autografts of fascia lata by Kirschner in 1910 [ 11 ] and fascial
strips by Gallie and Le Mesurier in 1923 [ 12 ] . Tendons, cutis,
and whole skin grafts, both homografts and heterografts,
have been advocated and found to have problems.
Nonbiological prosthetics that have been used in the past
include stainless steel and tantalum gauze. More recently
polypropylene (Marlex, Prolene), polyester (Mersilene), and
A. N. Kingsnorth (*)
Department of Surgery , Peninsula College of Medicine & Dentistry ,
Plymouth , Devon, UK
e-mail: andrew.kingsnorth@nhs.net
10 ] both described repair techniques
1, 2 ] . Laparoscopic
8 ] . Judd in 1912 [ 9 ]
ePTFE (DualMesh Plus) have been introduced and are the
materials of choice for many surgeons (these are reviewed in
Chap. 7).
The ideal prosthetic material has yet to be discovered.
The visionary Theodor Billroth stated more than a century
ago, “If we could arti fi cially produce tissues of the density
and toughness of fascia or tendon, the secret of radical
cure of hernia would be discovered” [ 13 ] . The currently
available products, however, are generally excellent
alternatives to the native tissues when the repair of these
hernias is undertaken.
Symptoms and Signs
An incisional hernia is de fi ned by Pollock and his colleagues
as “a bulge visible and palpable when the patient is standing
and often requiring support or repair” [ 14 ] .
Sixty percent of patients with incisional hernias do not
experience any symptoms; however, symptoms that predicate medical advice include dif fi culty 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. 21.1 ). This complication
is more likely in infra-umbilical hernia. It may be exacerbated
by friction of clothes or corsetry [ 15 ] . Hernias after gyneco-
logical and obstetric interventions are most at risk [ 16 ] .
The demonstration of small incisional hernias may be
very dif fi cult. 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
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_21, © Springer Science+Business Media London 2013
325
326 A.N. Kingsnorth
Fig. 21.1 Spontaneous rupture of an incisional hernia
examination of the abdominal wall is dependent upon a
skilled interpreter. It is sometimes dif fi cult to differentiate
between a hernia and subcutaneous fat or small bowel in
the hernia vs. in close proximity to a weakened anterior
fascia. In most situations and particularly for massive
complex incisional hernias, CT scan may be much more
ef fi cient and accurate in de fi ning 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 de fi nes
the contents of the sac especially if the abdominal wall
hernias are clinically occult. In addition it distinguished
them from other diseases such as hematoma, abscess, and
neoplasia [ 17 ] .
Incidence
The overall incidence of incisional hernias is dif fi cult to estimate. Homans, in 1887, reported that 10% of abdominal
operations were followed by incisional hernias [ 18 ] . The
reported incidence of this complication has not fallen in
recent years, even though major sepsis has diminished,
mono fi lament, nonabsorbable sutures have been introduced,
and the technique of wound closure has been emphasized.
Incisional hernias are slightly more frequent in males than
females (55:45).
Until recently there were very few studies with adequate
follow-up of laparotomy wounds to determine the real incidence of incisional hernia. Stanton, in 1916, reported 500
consecutive laparotomies followed up for 5–7 years. Over
this period a total of 24 postoperative hernias were found
(4.8%). In 260 clean cases only three incisional hernias
developed, whereas in 186 contaminated cases 18 hernias
developed [
19 ] .
Although the incidence of burst abdomen has been
reduced by the use of high-tensile sutures, incisional hernia
remains an important problem. The strength of the abdominal wall resides in the aponeurotic layers, the linea alba, and
the rectus sheath. These layers are slow to heal and only
regain adequate strength after 120 days from wounding [ 20 ] .
On a theoretical basis, most incisional hernias would be
expected to be apparent before this healing is complete. The
reports of onset of incisional hernia which occur in the standard textbooks are usually based on the information gleaned
from patients having repair operations for symptomatic incisional hernias; hence, they probably overemphasize these
large and early onset hernias. For instance, Akman estimated
that 97% of incisional hernias were apparent at 5 years [
21 ] .
Long-term prospective studies of laparotomy wounds
were unknown until Hughes and Ellis separately raised the
question of late wound failure in the early 1980s. Ellis and
colleagues from the Westminster Hospital followed up 363
patients who had undergone laparotomy but who had sound
wounds without herniation when examined at 1 year. When
reviewed between 2 1 / 2 and 5 1 / 2 years later, 21 patients (5.8%)
had developed incisional hernias [ 22– 26 ] .
Mudge and Hughes from Cardiff have published an
important continuation of their study of incisional hernia
[ 26 ] . During the years 1972–1973, 831 patients aged over 40
years undergoing major abdominal surgery were entered into
a long-term study. Of 564 patients surviving and being willing to enter the study at the end of 1 year, 337 patients were
followed up for a further 9 years. Of the remainder, 128
patients had died and 99 patients had an incomplete followup for various reasons. All the patients were questioned
regarding symptoms and incapacity.
Of the 564 patients 62 (11%) had developed incisional
hernias by the de fi nition of Pollock. Of these 62 patients
developing incisional hernias, details of the original operative closure technique were known for 52 and for 408 patients
who did not develop hernias. The incidence of hernia in
patients having nylon closure to both peritoneum and linea
alba was 11 of 143 (7.7%); for catgut to peritoneum and
nylon to linea alba, 24 out of 196 developed incisional hernia
(12%); for catgut to both layers, 14 out of 100 developed
incisional hernias (14%); of four patients having nylon
through-and-through tension sutures, two developed incisional hernias. When the 337 completing the 10-year followup are scrutinized, 37 (11%) developed an incisional hernia,
and 13 of these (35%) fi rst appeared at 5 years or later. One
in three of these hernias caused symptoms.
More than half the incisional hernias fi rst appeared more
than 1 year after the initial operation. These 10-year results
con fi rm that there is a continued attrition of the healed laparotomy wound, with incisional hernias developing up to and
after 10 years. When the distress and disability of the hernias
is considered, those that develop in the fi rst 3 years after
32721 Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
laparotomy cause the most symptoms; they are also the larger
hernias and are more likely to require repairs [
These fi ndings from two independent groups in London
and Cardiff con fi rm each other, the failure rate of abdominal
wounds being about 6% at 5 years rising to 11% at 10 years.
Akman’s earlier statement that 97% of incisional hernias
are apparent at 1 year after the original surgery is not
con fi rmed by these long-term studies. Moreover, without
full-scale prospective follow-up the incidence of incisional
hernia will be underestimated. Fortunately not all incisional
hernias warrant an operation.
Currently it is believed that up to 13% of laparotomy incisions will eventually develop hernias. In a systematic review
of et al. (see Chap. 6 ) [ 27 ] , it was concluded that abdominal
fascial closure of midline laparotomy wounds with a continuous, nonabsorbable suture results in a signi fi cantly lower
rate of incisional hernia than using either nonabsorbable or
interrupted techniques.
24 ] .
Etiologic Factors
The important causative factors include sepsis (60% of
patients developing an incisional hernia within the fi rst year
after surgery have had signi fi cant wound infection), the
placement of drainage tubes through the original incision, a
previous operation through the same incision within 6
months, initial closure with catgut alone (“inept methods of
suture”) [ 28, 29 ] , steroid and other immunosuppressant therapy, and in fl ammatory bowel disease. Obesity is an important risk factor both for the occurrence of the original
incisional hernia and for the likelihood of recurrence of the
hernia after repair [ 22, 30 ] . Early wound dehiscence is fre-
quently followed by incisional herniation. Needle puncture
incisional hernias are described as “satellites” of a main
wound failure or “button-hole” hernias. These hernias may
be related to the sawing effect of nonabsorbable sutures on
the aponeurosis [
gender, anemia, malnutrition, hypoproteinemia, diabetes,
type of incision, postoperative intestinal obstruction [
and postoperative chest infection. Two recent retrospective
reviews which included multifactorial regression analysis of
putative risk factors, such as sex, age, smoking, chronic lung
disease, obesity, sight, surgeon’s experience, closure method,
and suture material, have found that size of the hernia and
obesity were the prime factors involved in recurrence after
incisional hernia repair [ 32, 33 ] . Many of these hernias
recurred early with remedial time between the primary operation and the fi rst symptoms of hernia being within a year.
Other centers with a large experience have added further risk
factors which include age over 60 years, a previous attempt
at repair of the hernia, and postoperative complications [ 34 ] .
With time the lateral abdominal wall shortening occurs and
31 ] . Less signi fi cant factors include age and
32 ] ,
atrophy of the oblique musculature. This combined with
pathological fi brosis due to myopathic disuse atrophy of the
rectus abdominis muscles results in an increased transfer of
load forces to the midline at the time of repair increasing the
likelihood of recurrence [ 35 ] . Fifty- fi ve percent of incisional
hernias occur in men. Incisional hernias are infrequent under
the age of 40 years and their incidence increases with age.
There is an association between the development of incisional hernias and the occurrence of the post-thrombotic
syndrome [ 36 ] .
Of particular importance as an etiologic factor is the
wound drain. Ponka records that of 126 patients with herniation through a subcostal incision for biliary surgery all had
drains delivered through the wound at the time of the initial
operation [ 30 ] .
Midline incisions are at greater risk than paramedian inci-
37 ] . However, no matter which anatomic type of inci-
sions [
sion is made, the choice of suture material is crucial. Kirk
compared paramedian incisions closed with two layers of
catgut with midline incisions closed with nylon; the crucial
difference was not the anatomy of the incision but the choice
of suture—the nylon-closed incisions were signi fi cantly better than those closed with catgut [
Lower midline incisions seem to be at greater risk than
upper midline incisions (but this may be a faulty fi nding;
inadequate suture techniques as well as physiological factors
need assessment). Many of the lower midline incisions are
done for gynecological interventions, and the subsequent
hernias are often not included in purely “surgical” follow-up
data; hence, there may be under-recording of the true overall
incidence of this problem. The location of incisional hernias
has changed during recent years with the new generation of
laparoscopic operations that have evolved [ 39 ] .
Mass suture with wire is a secure method, and no late
incisional hernias developed in the cases closed with interrupted wire [ 40 ] . The newer absorbable polymer sutures
polyglactin (Vicryl) and polyglycolic acid PGA (Dexon)
have been subjected to trial and are reported as less good
than nonabsorbables for fascial closure. The longer life polymer polydioxanone (PDS) is under evaluation. A controlled
trial of PDS vs. polyamide (nylon) in the closure of 233
major laparotomy wounds failed to show any statistically
signi fi cant difference. The patients were randomized to either
suture, a mass-closure technique was used, and patients were
followed up to 6 months. There were two wound failures in
the PDS group and more sepsis in the PDS group. There
were no wound sinuses in either group [ 41 ] .
Late hernias occur just as frequently in patients whose
wounds are sutured with an absorbable polymer or nonabsorbable mono fi lament. At present there is no explanation of
why mature collagen should yield to form hernia so long
after healing has occurred. There is no etiological factor to
account for these late hernias [
38 ] .
24, 26 ] although the concept
328 A.N. Kingsnorth
of collagen failure, metastatic emphysema, may offer an
explanation (see page 69).
Epigastric incisional hernias are recently reported as a
complication of median sternotomy wounds for cardiac
surgery. The risk factors identi fi ed include male sex, obesity,
wound infection, aortic valve replacement, and left ventricular failure [
In children, either a layered or a mass closure with polyglycolic acid sutures gives acceptable results and a low failure rate. Nonabsorbable sutures are unnecessary in children
[ 43 ] . For some unknown reason the risk of failure in children is greatest in those undergoing pyloromyotomy
(Ramstedt’s) operation for hypertrophic pyloric stenosis
[ 44 ] . Early incisional hernias in children are likely to resolve
spontaneously. The late development of incisional hernias
occurs rarely in children [ 45 ] .
42 ] .
Principles of Open Repair
The following principles should be followed:
1. Whenever possible the normal anatomy should be recon-
stituted, 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 clo-
sure 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% [ 46 ] .
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 [ 24 ] .
3. The suture material must retain its strength for long
enough to maintain tissue apposition and allow sound
union of tissues to occur. A nonabsorbable or slowly
absorbable material must, therefore, be used.
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-cm intervals, the ratio of suture length to wound
length must be 4:1 and not more than 5:1 [ 47, 48 ] .
5. Repair of an incisional hernia inevitably involves return-
ing viscera to the con fi nes of the abdominal cavity with a
resultant rise in intra-abdominal pressure. It is important
to minimize this. Preoperative weight reduction is the fi rst
precaution. This, unfortunately, is generally not possible.
If the linea alba cannot be reconstituted without undue
tension, steps must be taken to perform a relaxing incision
such as an external oblique release (Ramirez procedure,
see below). This is almost always required with very large
hernias.
6. Every care must be taken to prevent abdominal disten-
sion 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. Restriction of preoperative smoking, chest exercises, weight reduction, and avoidance of excessive blood
or fl uid replacement (and their hemodynamic effects on
the heart) are important components in the successful
repair of an incisional hernia.
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 [ 49 ] .
Two more points should be considered:
1. The use of antibiotics. A randomized trial comparing the
use of antibiotic prophylaxis against no antibiotic in incisional hernia repair using a prosthesis has never been carried out. Nevertheless most surgeons consider it best
practice to administer a systemic dose of antibiotics preoperatively. When combined with a second dose of antibiotics, a signi fi cant reduction in wound infection occurs even
in the context of a clean operation without contamination
[ 50 ] . When there are other risk factors such as diabetes,
obesity, and previous wound infection, the need for antibiotic prophylaxis becomes imperative. The use of prosthetic
materials and in particular biological tissue grafts will be
addressed elsewhere in this book (Chap. 7).
2. The use of prosthetic synthetic or biological meshes.
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 [
synthetic meshes are designed to withstand the theoretical
maximum intra-abdominal 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 fi eld a biological mesh is favored, and
there are many new products to choose from [
A meta-analysis of randomized control trials with a Jadad
quality score of greater than 3 revealed that the lowest occurrence of incisional hernia occurred when nonabsorbable
sutures were used for abdominal wall closure and the suture
51 ] . Prosthetic,
52 ] .